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9 Cards in this Set

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  • Back
A patient is admitted to the hospital with Guillain-Barre syndrome. She had a weakness in her feet and ankles that has progressed to weakness with numbness and tingling in both legs. during the acute phas of her illness, the nurse recognizes that:

a. the most important aspect of care is to monitor the patient's vital capacity and ABGs
b. early treatment with corticosteroids can suppress the immune response and prevent ascending nerve damage
c. although voluntary motor neurons are damaged by the inflammatory response, the autonomic nervous system is unaffected by the disease
d. the most serious complication of this condition is ascending demyelination of the peripheral nerves of the lower brainstem and cranial nerves
a. The most serious complication of Guillain-Barre syndrome is respiratory failure, and it is essential that vital capacity and ABGs are monitored to detect involvement of the nerves that affect respiration. Plasmapheresis or administration of high-dose immunoglobulin results in a shortened recovery time. The peripheral nerves of both the sympathetic and parasympathetic nervous systems are involved in the disease and may lead to orthostatic hypotension, hypertension, and abnormal vagal responses affecting the heart. Guillain-Barre syndrome may affect the lower brainstem (facial, eye, and swallowing functions).
A patient with Guillain-Barre syndrome asks if he is going to die as the paralysis spreads toward his chest. In responding to the patient, the nurse knows that:

a. patients who require ventilatory support almost always die
b. death occurs when nerve damage affects the brain and meninges
c. most patients with Guillian-Barre syndrome make a complete recovery
d. if death can be prevented, residual paralysis and sensory impairement are usually permanent
c. As nerve involvement ascends, it is very frightening for the patient, but more than 85% of patients with Guillain-Barre syndrome recover completely with care. Patients also recover if ventilatory support is provided during respiratory failure, although 5% to 10% of patients die from respiratory failure or cardiac arrhythmias. Gullain-Barre syndrome affects only peripheral nerves and does not affect the brain.
A patient has a complete spinal cord transection at the C7 level. During the acute period, the nurse would expect the patient to have:

a. paraplegia with a flaccid paralysis
b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss
d. flaccid tetraplegia with loss of pressure sensation
b. Tetraplegia with motor and sensory loss is characteristic of a complete cord injury at the level of C8, with paraplegia with motor and sensory loss at the level o fT1. A hemiplegia occurs with central (brain) lesions affecting motor and sensory function, and any partial loss of function is associated with incomplete spinal cord lesions.
An initial incomplete spinal cord injury often results in complete cord damage because of:

a. edematous compression of the cord above the level of the injury
b. continued trauma to the cord resulting from damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. mechanical transection of the cord by sharp vertebral bone fragments after the intial injury
c. The primary injury of the spinal cord rarely affects the entire cord, bu the pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema secondary to the inflammatory response may increase the damage as it extends above and below the injury site.
The current standard of care for spinal cord injury within the first 8 hours of injury is treatment with:

a. dopamine (Intropin)
b. high-volume IV fluids
c. dexamethasone (Decadron)
d. methylprednisolone (Medrol)
d. Early, large-dose methylprednisolone is standard treatment for spinal cord injuries because it has been found to improve blood flow and reduce edema in the spinal cord following injury. Tirilazad (Freedox) has the same use as methylprednisolone with perhaps fewer side effects.
During the assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurse:

a. uses tracheal suctioning to remove secretions
b. assesses lung sounds and respiratory parameters q1-2hr
c. places the patient prone to promote drainage of respiratory secretions
d. explains to the patient that mechanical ventilation will be necessary to maintain respiratory function
b. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should frequently monitor the patient for breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment.
Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need:

a. IV fluids
b. tube feedings
c. nasogastric suctioning
d. total parenteral nutrition
c. During the first 2-3 days after a spinal cord injury, paralytic ileus may occur, and nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes.
A patient with a spinal cord lesion at C8 tells the nurse that he has a headache and feels flushed and warm. The first action by the nurse is to:

a. check the patient's temperature
b. take the patient's BP
c. elevate the head of the patient's bed
d. assess the patient for a distended bladder or rectum
b. Manifestations of autonomic dysreflexia include severe HTN, bradycardia, headache, blurred vision, and flushing and diaphoresis above the level of the lesion, and it is a life-threatening situation. At the first indication, the nurse should check the patient's BP, raise the head of the bed 45 degrees, and notify the physician if it is apparent that the problem is autonomic dysreflexia.
Two weeks following a spinal cord injury, the patient has a neurogenci bladder. The nurse recognizes that a neurogenic bladder:

a. has no reflex detrusor contractions
b. has sensory function but no motor function
c. has hyperactive reflect detrusor contractions
d. requires diagnostic evaluation to determine the best management interventions
d. A neurogenic bladder is any type of bladder dysfunction related to abnormal or absent bladder innervation and occurs not only with spinal cord injury but also with many other conditions as well. To determine what function the bladder has, diagnostic evaluation must be performed with cystometrograms and perhaps an IV pyelogram and urine culture before appropriate interventions can be instituted. The bladder may have various degrees of flaccidity or spasticity.