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The nurse is caring for a patient who has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which of the following nursing actions should be included in the plan of care?
- A. Assessment of the patient for left leg pain
- B. Assessment of the patient for left arm weakness
- C. Positioning the patient's right leg when turning the patient
- D. Teaching the patient to look at the left leg to verify its position
Correct Answer: C
Rationale: The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.
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The nurse is caring for a young adult patient with a T3 spinal cord injury who asks the nurse about whether he will be able to be sexually active. Which of the following initial responses by the nurse is best?
- A. Reflex erections frequently occur, but orgasm may not be possible.
- B. Sildenafil is used by many patients with spinal cord injury.
- C. Multiple options are available to maintain sexuality after spinal cord injury.
- D. Penile injection, prostheses, or vacuum suction devices are possible options.
Correct Answer: C
Rationale: Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
Which of the following actions should the nurse take when assessing a patient with trigeminal neuralgia?
- A. Examine the mouth and teeth thoroughly.
- B. Have the patient clench and relax the jaw and eyes.
- C. Identify trigger zones by lightly touching the affected side.
- D. Gently palpate the face to compare skin temperature bilaterally.
Correct Answer: A
Rationale: Oral hygiene is frequently neglected because of fear of triggering facial pain. Having the patient clench the facial muscles will not be useful because the sensory branches of the nerve are affected by trigeminal neuralgia. Light touch and palpation may be triggers for pain and should be avoided.
The nurse is teaching a patient who is at risk for Bell's palsy because of previous herpes simplex infection. Which of the following information should the nurse include?
- A. Call the doctor if pain or herpes lesions occur near the ear.
- B. Treatment of herpes with antiviral agents prevents Bell's palsy.
- C. You may be able to prevent Bell's palsy by doing facial exercises regularly.
- D. Medications to treat Bell's palsy work only if started before paralysis onset.
Correct Answer: A
Rationale: Pain or herpes lesions near the ear may indicate the onset of Bell's palsy and rapid corticosteroid treatment may reduce the duration of Bell's palsy symptoms. Antiviral therapy for herpes simplex does not reduce the risk for Bell's palsy. Corticosteroid therapy will be most effective in reducing symptoms if started before paralysis is complete but will still be somewhat effective when started later. Facial exercises do not prevent Bell's palsy.
The nurse is caring for a patient with Bell's palsy who refuses to eat while others are present because of embarrassment about drooling. Which of the following responses is best for the nurse to do?
- A. Respect the patient's desire and arrange for privacy at mealtimes.
- B. Teach the patient to chew food on the unaffected side of the mouth.
- C. Offer the patient liquid nutritional supplements at frequent intervals.
- D. Discuss the patient's concerns with visitors who arrive at mealtimes.
Correct Answer: A
Rationale: The patient's desire for privacy should be respected to encourage adequate nutrition and reduce patient embarrassment. Liquid supplements will reduce the patient's enjoyment of the taste of food. It would be inappropriate for the nurse to discuss the patient's embarrassment with visitors unless the patient wishes to share this information. Chewing on the unaffected side of the mouth will enhance nutrition and enjoyment of food but will not decrease the drooling.
The nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury. Which of the following goals should the nurse include for this patient?
- A. Transfer independently to a wheelchair.
- B. Drive a car with powered hand controls.
- C. Turn and reposition independently when in bed.
- D. Push a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.