Spinal
Explain the difference between the two degrees of spinal cord injury: Complete and Incomplete.
Complete: TOTAL loss of sensory and motor function below the level of injury
Incomplete (partial): MIXED loss of voluntary motor activity and sensation - some tracts are still intact
The nurse who notes that a 59-year-old female patient has lost 1 inch in height over the past 2 years will plan to teach the patient about
a. discography studies.
b. myelographic testing.
c. magnetic resonance imaging (MRI).
d. dual-energy x-ray absorptiometry (DXA).
D. The decreased height and the patient's age suggest that the patient may have osteoporosis and that bone density testing is needed. Discography, MRI, and myelography are typically done for patients with current symptoms caused by musculoskeletal dysfunction and are not the initial diagnostic tests for osteoporosis.
The nurse teaches individuals that one of the best ways to prevent musculoskeletal injuries during physical exercise is by doing what?
A. Increase muscle strength with daily isometric exercise
B. Avoid exercising on concrete or hard pavement surfaces
C. Perform stretching and warm-up exercises before exercise
D. Wrap susceptible joints with elastic bandages or adhesive tape before exercise
Answer: C Perform stretching and warm-up exercises before exercise
Rationale: stretching and warming up will help to pre-lengthen tissues that could potentially be strained, avoid quick stretching but a slow, smooth movement – warm up exercises help warming the muscle which helps with proper oxygenation, cell metabolism and speed of nerve impulses in them.
A nurse is caring for a client who injured her lower back during a fall and describes sharp pain in her back and down her left leg. In which of the following positions should the nurse plan to place the client to attempt to decrease her pain?
A. Prone without use of pillows
B. Semi-Fowler’s with a pillow under the knees
C. High-Fowler’s with the knees flat on the bed
D. Supine with the head flat
Answer: B. Semi-Fowler’s with a pillow under the knees
Rationale: AKA William’s position = Semi-Fowler’s with knees flexed by pillows is used to relieve low back pain caused by a bulging disk and nerve root involvement.
A client with RA tells the nurse, “I know it is important to exercise my joints so that I won’t lose mobility, but my joints are so stiff and painful that exercising is difficult.” Which of the following responses by the nurse would be most appropriate?
A. “You are probably exercising too much. Decrease your exercise to every other day”
B. “Tell the physician about your symptoms. Maybe your analgesic medication can be increased.”
C. “Stiffness and pain are part of the disease. Learn to cope by focusing on activities you enjoy.”
D. “Take a warm bath or shower before exercising. This may help with your discomfort.”
Answer: D. “Take a warm bath or shower before exercising. This may help with your discomfort.”
Rationale: Superficial heat applications can be helpful in relieving pain and stiffness making exercise more comfortable and effective after heat application. Rest and exercise must be balanced every day, not every other day. Would like to avoid larger doses of analgesics if other methods are effective.
When planning care for a patient with a C5 SCI, which nursing diagnosis is the highest priority?
A. Risk for impairment of tissue integrity caused by paralysis
B. Altered patterns of urinary elimination caused by quadriplegia
C. Altered family and individual coping caused by the extent of trauma
D. Ineffective airway clearance caused by high cervical SCI
Answer: D. Ineffective airway clearance caused by high cervical SCI
Rationale: Maintaining a patent airway is the highest priority with high cervical SCI’s since high cervical injuries tend to affect airway and breathing (diaphragm, etc.)
A patient with left knee pain is diagnosed with bursitis. The nurse will explain that bursitis is an inflammation of
a. the synovial membrane that lines the joint.
b. a small, fluid-filled sac found at some joints.
c. the fibrocartilage that acts as a shock absorber in the knee joint.
d. any connective tissue that is found supporting the joints of the body.
B. Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.
A patient with a fractured right hip has an anterior open reduction and internal fixation of the fracture. What should the nurse plan to do postoperatively?
A. Get the patient up to the chair on the first postoperative day
B. Position the patient only on the back and the un-operative side
C. Keep the leg abductor pillow on the patient even when bathing
D. Ambulate the patient with partial weight bearing by discharge
Answer: A. Get the patient up to the chair on the first postoperative day
Rationale: Since the fracture site was internally fixed with pins or plates, the fracture site is stable and the patient can be moved from the bed to the chair on the first postoperative day – ambulation will begin on the first or second day postoperative WITHOUT weight bearing on the affected leg. ---- patient can be placed on operative side --- abductor pillow is for Total hip replacement
The nurse is conducting health screening for osteoporosis. Which client is at greatest risk of developing this disorder?
A. A 25 year old woman who runs
B. A 36 year old man who has asthma
C. A 70 year old man who consumes excess alcohol
D. A sedentary 65 year old woman who smokes cigarettes
Answer: D. A sedentary 65 year old woman who smokes cigarettes
Rationale: Osteoporosis risk factors include female gender, being postmenopausal, advanced age, low-calcium diet, excessive alcohol intake, being sedentary, smoking cigarettes
Teach the patient with fibromyalgia the importance of limiting intake of which foods (select all that apply)?
A. Sugar
B. Alcohol
C. Caffeine
D. Red Meat
E. Root vegetables
Answer: A, B, C
Rationale: Sugar, alcohol and caffeine may cause muscle irritation
A nurse is caring for a patient admitted with a spinal cord injury. The patient shows a complete loss of motor, sensory, and reflex activity below the level of injury. The nurse recognizes this condition as which of the following?
A. Central cord syndrome
B. Spinal shock syndrome
C. Anterior cord syndrome
D. Brown-Sequard
Answer: B Spinal Shock Syndrome
Rationale: Spinal Shock: decrease/loss in reflexes (motor), loss of sensation, flaccid paralysis below level of injury – lasts days to weeks
Central Cord Syndrome: motor weakness and sensory loss, Lower extremities not usually affected, dysesthetic burning pain in upper extremities
Anterior Cord Syndrome: damage to anterior spinal artery (compromises blood flow), motor paralysis and loss of pain and temperature sensation below level of injury
Brown-Sequard Syndrome: damage to one-half of cord, ispsilateral (same side as injury) loss of motor function and pressure, position, and vibration sense; contralateral loss of light touch, pain, and temperature sensation
Which medication information will the nurse identify as a concern for a patient's musculoskeletal status?
a. The patient takes a daily multivitamin and calcium supplement.
b. The patient takes hormone therapy (HT) to prevent "hot flashes."
c. The patient has severe asthma and requires frequent therapy with oral corticosteroids.
d. The patient has migraine headaches treated with nonsteroidal antiinflammatory drugs (NSAIDs).
C. Frequent or chronic corticosteroid use may lead to skeletal problems such as avascular necrosis and osteoporosis. The use of HT and calcium supplements will help prevent osteoporosis. NSAID use does not increase the risk for musculoskeletal problems.
A patient with an extracapsular hip fracture is admitted to the orthopedic unit and placed in Buck’s traction. The nurse explains to the patient that the purpose of the traction is to do what?
A. Pull bone fragments back into alignment
B. Immobilize the leg until healing is complete
C. Reduce pain and muscle spasms before surgery
D. Prevent damage to the blood vessels at the fractured site
Answer: C. Reduce pain and muscle spasms before surgery
Rationale: Buck’s traction is a type of skin traction used to immobilize a fracture, prevent hip flexion contractures, and reduce muscle spasms, therefore reduces pain too before surgery.
A patient is being discharged after 2 weeks of IV antibiotic therapy for acute osteomyelitis in the left leg. Which information will be included in the discharge teaching?
A. The reason for taking oral antibiotics for 7-10 days after discharge
B. The need for daily aerobic exercise to help maintain muscle strength
C. How to monitor and care for the long-term IV catheter site
D. How to apply warm packs safely to the leg to reduce pain
Answer: C. How to monitor and care for the long-term IV catheter site
Rationale: Acute osteomyelitis is treated with IV antibiotics for 4-6 weeks or longer. This may be started in the hospital and then continued at home. The nurse must educate on signs of infection at the IV site and how to care for the catheter even during daily activities like bathing. Avoid exercise and heat application since this can increase swelling and the risk for infection.
In teaching a patient with Systemic Lupus Erythematosus (SLE) about the disorder, the nurse knows the pathophysiology of SLE includes:
A. Circulating immune complexes formed from IgG autoantibodies reacting with IgG
B. An autoimmune T-cell reaction that results in destruction of the deep dermal skin layer
C. Immunologic dysfunction leading to chronic inflammation in the cartilage of muscles
D. The production of a variety of autoantibodies directed against components of the cell nucleus
Answer: D. The production of a variety of autoantibodies directed against components of the cell nucleus
Rationale: In SLE, autoantibodies are produced against nucleic acids, erythrocytes, coagulation proteins, lymphocytes, platelets and other self-proteins and the autoimmune reactions typically are directed at the constituents of the cell nucleus, especially the DNA. Eventually this leads to tissue destruction and affects the kidneys, heart, skin, brain and joints.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with an acute SCI?
a. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses
Answer: A. Bradycardia
Rationale: Neurogenic shock is due to the loss of vasomotor tone due to injury and is characterized by HYPOtension and bradycardia – loss os sympathetic nervous system innervation causes the peripheral vasodilation, venous pooling and decreased cardiac output (hypotension)
The nurse notes crackling sounds and a grating sensation with palpation of an older patient's elbow. How will this finding be documented?
a. Torticollis
b. Crepitation
c. Subluxation
d. Epicondylitis
B. Crackling sounds and a grating sensation that accompany movement are described as crepitus or crepitation. Torticollis is a twisting of the neck to one side, subluxation is a partial dislocation of the joint, and epicondylitis is an inflammation of the elbow that causes a dull ache that increases with movement.
What are the 6 P’s of compartment syndrome?
Answer: Pain, Pressure, Paresthesia, Pallor, Paralysis, Pulselessness
Rationale: Pain much more then from expected with the type of injury and not managed by opioid analgesics, Pressure, Paresthesia is numbness or tingling, pallor (coolness, loss of normal color of extremity), paralysis or loss of function, pulselessness (or diminished peripherally)
When receiving discharge instructions, a patient with osteoporosis makes all of these statements. Which statement indicates to the nurse that the patient needs additional teaching?
A. “I take my ibuprofen every morning as soon as I get up”
B. “My daughter removed all of the throw rugs in my home.”
C. “My husband helps me every afternoon with range-of-motion exercises”
D. “I rest in my reclining chair every day for at least an hour”
Answer: A. “I take my ibuprofen every morning as soon as I get up”
Rationale: Ibuprofen can cause abdominal discomfort or pain and ulceration of the GI tract. It should be taken with meals or milk. Removal of throw rugs help prevent falls, ROM exercises and rest are important to help cope with osteoporosis.
A nurse is providing information to a client who has osteoarthritis of the hip and knee. Which of the following information should the nurse include in the information? (Select all that apply).
A. Apply heat to joints to alleviate pain
B. Ice inflamed joints following activity
C. Install an elevated toilet seat
D. Take tub baths
E. Complete high-energy activities in the morning
Answer: A, B, C, E
Rationale: Applying heat to joints can provide temporary relief of pain, applying ice to inflamed joints following activity can decrease edema, An elevated toilet seat can help decrease strain and pain of affected joints, high-energy activity in the morning is recommended as part of a daily routine to promote independence. Tub bath increases risk for strain and pain of affected joints when getting in and out of the tub and increases risk for falls.
The nurse is caring for a patient admitted over a week ago with an acute SCI. Which of the following assessments would alert the nurse to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache
Answer: D. Throbbing headache
Rationale: Autonomic dysreflexia may occur once reflexes return after spinal shock is resolved and if the injury is at T6 or higher. This is related to reflex stimulation of the sympathetic nervous system and the parasympathetic system is unable to counteract this response (below the level of the SCI). This results in hypertension (systemic), bradycardia (above level of SCI), throbbing headache (HTN), and diaphoresis above level of injury. Bradycardia because the parasympathetic NS is trying to compensate.
Most common cause is bladder irritation – may need to immediately catheterize
Nursing interventions – elevate HOB, notify HCP, assess for and remove cause (catheterization, remove stool impaction, remove constricted clothing/tight shoes), monitor and treat BP
Which finding from a patient's right knee arthrocentesis will be of concern to the nurse?
a. Cloudy fluid
b. Scant thin fluid
c. Pale yellow fluid
d. Straw-colored fluid
A. The presence of purulent fluid suggests a possible joint infection. Normal synovial fluid is scant in amount and pale yellow/straw-colored.
Correctly put the multistage fracture healing process (union) in the correct order:
A. Ossification
B. Remodeling
C. Fracture Hematoma
D. Granulation tissue
E. Callus Formation
F. Consolidation
Correct Order: C, D, E, A, F, B
Rationale:
1. Fracture Hematoma – bleeding creates hematoma surrounding ends of fragments (72 hours after injury)
2. Granulation Tissue – active phagocytosis absorbs local necrosis debris, hematoma turns into granulation tissue (blood vessels, fibroblasts and osteoblasts), forms basis for a new bone (osteoid) – 3-14 after injury
3. Callus Formation – minerals (calcium, phosphorus, magnesium) and new bone matrix are deposited in the osteoid, callus is made up of cartilage, osteoblasts, calcium, phosphorus – 2nd week after injury – can see on X-ray
4. Ossification – 3weeks – 6months after fracture and continues until 100% healed, limited mobility allowed at this time, bone hardening/strengthening
5. Consolidation – callus continues to develop, distance between fragments decreases and closes, ossification continues in this stage – up to a year following injury
6. Remodeling – Excess bone tissue is reabsorbed in this final stage, union is complete
A nurse is providing teaching for a client who has a history of low back injury. Which of the following instructions should the nurse give the client to prevent future problems with low back pain?
A. Engage in regular exercise including walking
B. Sit for up to 10 hours each day to rest the back
C. Maintain weight within 25% of ideal body weight
D. Create a smoking cessation plan
E. Wear low-heeled shoes
Answer: A, D, E
Rationale: Regular exercise (walking or swimming) can help prevent low back pain, stopping or cutting down on smoking can decrease problems with low back pain since smoking can cause disk degeneration, low-heeled and well-fitting shoes can prevent low back pain and high-heeled shoes should be avoided. Long periods of sitting or standing can cause low back pain – the use of footstools may be helpful when sitting, the patient should maintain weight within 10% of ideal body weight since obesity can increase low back pain.
A patient with rheumatoid arthritis is experiencing articular involvement. The nurse recognizes these characteristic changes include (select all that apply).
A. Bamboo-shaped fingers
B. Metatarsal head dislocation in feet
C. Noninflammatory pain in large joints
D. Asymmetric involvement of small joints
E. Morning stiffness lasting 60 minutes or more
Answer: B, E
Rationale: Joint stiffness occurs after periods of inactivity in RA (morning stiffness lasts from 60 mins to several hours), Fingers tend to become spindle shaped from synovial hypertrophy and thickening of the joint capsule, RA joint symptoms occur symmetrically and is inflammatory (heat, swelling, tenderness), metatarsal head dislocation may eventually occur in the feet and be painful.