Nokea
The client is having a lumbar puncture performed. The nurse would plan to place the client in which position for the procedure?
- A. Side-lying, with legs pulled up and head bent down onto the chest
- B. Side-lying, with a pillow under the hip
- C. Prone, in a slight Trendelenburg's position
- D. Prone, with a pillow under the abdomen
Correct Answer: A
Rationale: The side-lying position with legs pulled up and head bent down onto the chest is the standard position for a lumbar puncture. This position maximizes the space between the vertebrae, allowing easier access to the subarachnoid space for cerebrospinal fluid (CSF) collection. Proper positioning is critical to ensure the procedure is performed safely and effectively.
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In the spinal cord:
- A. Hemisection of the cord (Brown-Sequard Syndrome) results in paralysis and loss of touch and proprioception on the same side and loss of pain and temperature sensation on opposite side
- B. The cord ends at L3
- C. The lateral corticospinal tract is an important motor tract
- D. The blood supply at each level is in danger because of poor anastomoses
Correct Answer: A
Rationale: Brown-Sequard Syndrome involves ipsilateral motor and proprioceptive loss and contralateral pain/temperature loss due to hemisection of the spinal cord. This is due to the decussation of sensory pathways.
As the action potential swings down,
- A. potassium ions move out of the axon.
- B. potassium ions move into the axon.
- C. sodium ions move into the axon.
Correct Answer: A
Rationale: During the repolarization phase of an action potential, potassium ions move out of the axon, restoring the negative charge inside the neuron. This efflux of potassium ions helps return the membrane potential to its resting state after depolarization. The movement of potassium ions is facilitated by voltage-gated potassium channels, which open in response to the change in membrane potential.
Bilateral affection of spinal cord at the cervical level may produce the following syndrome:
- A. hemiplegia
- B. paraplegia
- C. tetraplegia
- D. monoplegia
Correct Answer: C
Rationale: Tetraplegia is the correct answer because damage to the cervical spinal cord affects both the upper and lower limbs, resulting in paralysis of all four extremities. This condition occurs due to the disruption of motor and sensory pathways at the cervical level, which control limb function.
The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have?
- A. Indoor mobility in manual wheelchair
- B. Ambulate with crutches and leg braces
- C. Be independent in self-care and wheelchair use
- D. Completely independent ambulation with short leg braces and canes
Correct Answer: C
Rationale: Independence in self-care and wheelchair use is realistic for T4 injuries.
Which of the following nursing interventions should be done in the case of a client who has a head injury obtained from being thrown off of a motorcycle?
- A. Assess LOC every hour or more often if needed
- B. Put the code cart outside the client's room
- C. Keep the client quiet in bed
- D. Allow one visitor at a time
Correct Answer: A
Rationale: Frequent assessments of LOC are critical to detect worsening neurological status.