NUR 2212 NEURO.
A nurse is teaching a client with multiple sclerosis (MS) about how to manage
urinary retention. Which instructions should the nurse
... [Show More] include in the teaching
session? Select all that apply.
Correct1 Using Credé maneuver
2 Using an indwelling catheter
3 Using anticholinergic medications
4 Monitoring and restricting fluid intake to 800 mL daily
Correct5 Monitoring for and reporting signs of urinary tract infection
Credé maneuver is the use of manual pressure over the suprapubic area to compress the bladder and
promote emptying. Urinary retention is a risk factor for urinary tract infection. Physical stressors, such as
infections, can trigger exacerbations in clients with multiple sclerosis. Early recognition and treatment of
infection is important to decrease the risk of exacerbation in the client with multiple sclerosis. Use of an
indwelling urinary catheter puts the client at risk for urinary tract infection. Some clients with urinary
retention are taught intermittent selfcatheterization. Risk of urinary tract infection is lower with intermittent
catheterization than with the use of an indwelling urinary catheter. Acetylcholine is the primary
neurotransmitter of the parasympathetic nervous system. Stimulation of the parasympathetic nervous
system causes the detrusor muscle to contract, which promotes bladder emptying. Anticholinergic
medications inhibit the cholinergic response and lead to urinary retention. Oral fluids should be
encouraged in the client with voiding difficulties as concentrated urine increases the risk of urinary tract
infection.
A client has a diagnosis of multiple sclerosis and is currently in remission. The client
is a parent of two active preschoolers. What should the nurse encourage the client
to do?
1 Plan a schedule of specific times each day that will be set aside for playtime with the children.
2 While in remission, provide support to other people with multiple sclerosis who also have young
children.
Correct3 Develop a flexible schedule for completion of routine daily activities.
4 Meet with a selfhelp group for people with the diagnosis of multiple sclerosis.
The client must be flexible and adjust activities to provide for rest when necessary; activity should cease
before the point of fatigue. Although quality time with children is important, it must be done on a flexible
schedule to prevent fatigue. Although laudable, providing support to other people with multiple sclerosis
who also have young children cannot be done if the client is in need of support or if it overtaxes physical
resources. Meeting with a selfhelp group for people with the diagnosis of multiple sclerosis may not be a
need at this time; prevention of fatigue always is important.
71.
A young man who sustained a spinal cord injury at the cervical level expresses
concern about sexual functioning. What should the nurse do when counseling this
client?
Correct1
Consider that the client most likely will be able to have reflex penile erections.
Incorrect2
Arrange for the client to see the healthcare provider because sexual performance is unlikely.
3
Discourage the client from forming sexual relationships because little pleasure will be possible.
4
Reassure the client that he will be able to have sexual relationships with the ability to reproduce.
The reflex arc for sexual activity is intact; control of ejaculation is not. The ability to perform sexually is
determined on an individual basis. There are many ways to fulfill sexual needs. Reassuring the client that
he will be able to have sexual relationships with the ability to reproduce may provide false reassurance.
The ability to function is determined on an individual basis.
81.
A young adult client is hospitalized with a spinal cord injury. The client, knowing that
the paralysis may be permanent, says, "I wish God would end my suffering and take
me." What is the most therapeutic initial response by the nurse?
1
"You shouldn't give up hope."
Correct2
"Being incapacitated is difficult for you."
3
"Would you like to speak to a religious advisor?"
Incorrect4
"Have you talked to your family about your feelings?"
The response "Being incapacitated is difficult for you" is an openended, accepting response that permits
and encourages the client to continue to express feelings. The response "You shouldn't give up hope"
rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to
speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to
someone else. The response "Have you talked to your family about your feelings?" changes the focus
from the client's feelings to the family's role.
99.
A client has a functional transection of the spinal cord at C7-8, resulting in spinal
shock. Which clinical indicators does the nurse expect to identify when assessing
the client immediately after the injury? Select all that apply.
1
Spasticity
Incorrect2
Incontinence
Correct3
Flaccid paralysis
Incorrect4
Respiratory failure
Correct5
Lack of reflexes below the injury
Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in
flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks.
Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the
level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of
urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is
unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury
is below C4 and respirations are not affected.
What is the immediate nursing intervention for a client experiencing autonomic
dysreflexia?
1
Administering an alpha blocker
Correct2
Placing the client in a sitting position
3
Giving nifedipine or nitrate as prescribed
4
Monitoring blood pressure every 15 minutes
The immediate nursing intervention for a client experiencing autonomic dysreflexia is to place the client in
sitting position to prevent falls. A client with recurrent autonomic dysreflexia is administered an alpha
blocker as a prophylactic treatment. Nifedipine or nitrates are given after the client is placed in a stable
sitting position. Blood pressure is monitored after the client is in a stable position.
98.
The nurse is caring for a client with autonomic dysreflexia. What should be the
nurse’s immediate action to manage the client’s condition?
1
Covering the client with blanket
Correct2
Placing the client in a sitting position
3
Assessing the client’s urinary retention
4
Administering alpha blockers to the client
A client with autonomic dysreflexia should be first placed in the sitting position. Clients with hypothermia
should be covered with a blanket. A client’s urinary retention can be assessed once the condition is
stabilized. After performing all the assessments, the client should be provided medications such as alpha
blockers.
87.
Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffeeground material and appears restless and apprehensive. What is the most
important initial nursing action?
1
Change the client's diet to bland.
2
Obtain a stool specimen for occult blood.
Correct3 Prepare for insertion of a nasogastric tube.
4 Monitor recent laboratory reports for hemoglobin levels.
The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should
monitor the amount and characteristics of the drainage. Coffeeground gastric fluid indicates blood that
has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's
diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for
occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory
reports for hemoglobin levels is unsafe; the client needs immediate medical attention.
96.
Which statement regarding treatment with interferon indicates that the client
understands the nurse's teaching?
Correct1 "I will drink 2 to 3 quarts (2 to 3 liters) of fluid a day."
2 "Any reconstituted solution must be discarded in 1 week."
3 "I can continue driving my car as long as I have the stamina."
4 "While taking this medicine I should be able to continue my usual activity."
Adequate fluid intake helps to flush the kidneys and prevent nephrotoxicity, especially during the early
phase of treatment. Reconstituted solution may be stored in the refrigerator for 1 month. Confusion,
dizziness, and hallucinations are side effects of this drug; the client should avoid hazardous tasks, such
as driving or using machinery. Activity may have to be altered because fatigue and other flulike symptoms
are common with this drug.
The nurse is caring for a client with a spinal cord injury. The client exhibits signs of
autonomic hyperreflexia. What does the nurse recall is the most common cause of
this response?
1
Hemodynamic changes related to tilt table positioning
2
Deteriorating myelin sheath
Correct3
Distended large intestine
4
Crushed spinal cord
Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of
injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating,
and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding
headache. The client being upright on a tilt table is not involved in the autonomic
hyperreflexia[1] [2] phenomenon. The myelin sheath deteriorating is not involved in the autonomic
hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the
autonomic hyperreflexia phenomenon.
76.
The nurse is caring for a client one week after the client experienced a spinal cord
injury at the T3 level. What is an appropriate short-term goal for this client?
1
"The client will understand limitations."
2
"The client will consider lifestyle changes."
3
"The client will perform independent ambulation."
Correct4
"The client will carry out personal hygiene activities."
If the client has the capability to perform personal hygiene activities, it will help maintain a positive
identity. Understanding limitations, considering lifestyle changes, and performing independent ambulation
are necessary for progression to longterm goals. [Show Less]