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The nurse is caring for a patient with trigeminal neuralgia who has had a glycerol rhizotomy. Which of the following interventions should the nurse implement?
- A. Ask whether the patient is using an eye shield at night.
- B. Determine whether the patient is doing daily facial exercises.
- C. Question the patient about social activities with family and friends.
- D. Remind the patient to chew food on the unaffected side of the mouth.
Correct Answer: C
Rationale: Because withdrawal from social activities is a common manifestation of trigeminal neuralgia, asking about social activities will help in evaluating whether the patient's symptoms have improved. Glycerol rhizotomy does not damage the corneal reflex or motor functions of the trigeminal nerve, so there is no need to use an eye shield, do facial exercises, or take precautions with chewing.
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The nurse is admitting a patient with a spinal cord injury. Which of the following collaborative and nursing actions should the nurse do immediately? (Select all that apply.)
- A. Stabilize spine with sand bags
- B. Nasogastric (NG) tube feeding
- C. Ensure patency of airway
- D. Avoidance of cool room temperature
- E. Insert Foley catheter
Correct Answer: A,C,E
Rationale: Immediate care for a patient with a spinal cord injury is to ensure a patent airway, stabilize the spine with a hard collar or sand bags, and insert a Foley catheter. Avoidance of a cool room temperature is not part of immediate care. A tube feeding would not be initiated in the immediate postinjury care period.
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.
The nurse is caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury. Which of the following nursing actions has the highest priority?
- A. Assessment of respiratory rate and depth
- B. Continuous cardiac monitoring for bradycardia.
- C. Application of pneumatic compression devices to both legs
- D. Administration of methylprednisolone infusion
Correct Answer: A
Rationale: Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
The nurse is caring for a patient who has Guillain-Barré syndrome. Which of the following assessment data obtained by the nurse will require the most immediate action?
- A. The patient has continuous drooling of saliva.
- B. The patient's blood pressure (BP) is 106/50 mm Hg.
- C. The patient's quadriceps and triceps reflexes are absent.
- D. The patient complains of severe tingling pain in the feet.
Correct Answer: A
Rationale: Drooling indicates decreased ability to swallow, which places the patient at risk for aspiration and requires rapid nursing and collaborative actions such as suctioning and possible endotracheal intubation. The foot pain should be treated with appropriate analgesics, and the BP requires ongoing monitoring, but these actions are not as urgently needed as maintenance of respiratory function. Absence of the reflexes should be documented, but this is a common finding in Guillain-Barré syndrome.
The nurse is caring for a patient with paraplegia resulting from a T10 spinal cord injury who has a neurogenic reflex bladder. Which of the following actions should the nurse include in the plan of care?
- A. Educate on the use of the Credé method.
- B. Teach the patient how to self-catheterize.
- C. Catheterize for residual urine after voiding.
- D. Assist the patient to the toilet every 2 hours.
Correct Answer: B
Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.