Quiz MS

The nurse is caring for the client who has suffered spinal cord injury. The nurse further monitors the client for signs of autonomic dysreflexia and suspects this complication if which sign/symptom is noted?

• Sudden tachycardia

• Pallor of the face and neck

• Severe, throbbing headache

• Severe and sudden hypotension

Answer explanation

The client with spinal cord injury above the level of T7 is at risk for autonomic dysreflexia. It is characterized by a severe, throbbing headache, flushing of the face and neck, bradycardia, and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. It is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury.

The client with spinal cord injury is prone to experiencing autonomic dysreflexia. The least appropriate measure to minimize the risk of autonomic dysreflexia is which action?

• Strictly adhering to a bowel retraining program

• Keeping the linen wrinkle-free under the client

• Avoiding unnecessary pressure on the lower limbs

• Limiting bladder catheterization to once every 12 hours

Answer explanation

The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be performed every 4 to 6 hours, and indwelling bladder catheters should be checked frequently for kinks in the tubing. It is not appropriate to catheterize the client every 12 hours. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

The client with spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking vital signs, which immediate action would the nurse take?

• Raise the head of the bed and remove the noxious stimulus.

• Lower the head of the bed and remove the noxious stimulus.

• Lower the head of the bed and administer an antihypertensive agent.

• Remove the noxious stimulus and administer an antihypertensive agent.

Answer explanation

Key nursing actions are to sit the client up in bed, remove the noxious stimulus, and bring the blood pressure under control with antihypertensive medication per protocol. The nurse can also clearly label the client's chart identifying the risk for autonomic dysreflexia. Client and family should be taught to recognize, and later manage, the signs and symptoms of this syndrome.

A client has been examined in the clinic and has been diagnosed with pelvic inflammatory disease. The client asks the nurse to describe this condition. Which description of pelvic inflammatory disease by the nurse is accurate?

• "Pelvic inflammatory disease is pain that occurs during ovulation."

• "Pelvic inflammatory disease is also known as primary dysmenorrhea."

• "Pelvic inflammatory disease is the cause of cessation of menstruation."

• "Pelvic inflammatory disease is an infectious process that involves the uterine, tubes and uterus."

Answer explanation

Pelvic inflammatory disease (PID) is an infectious process that most commonly involves the uterine (fallopian) tubes (salpingitis), and uterus. Multiple organisms have been found to cause PID, and most cases are associated with more than one organism. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Primary dysmenorrhea refers to menstrual pain without identified pathology. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation and can be due to a variety of causes.

The nurse is collecting data from a client who is suspected of having mittelschmerz. Which statement supports this probable diagnosis?

• "My monthly cycle is very heavy."

• "I experience pain that occurs during intercourse."

• "I have incapacitating pain for the first few days of my menstrual cycle."

• "I experience a sharp pain located on my low right side midway through my cycle."

Answer explanation

Some women will experience slight vaginal bleeding at the time they experience mittelschmerz. Mittelschmerz (middle pain) refers to pelvic pain that occurs midway between menstrual periods or at the time of ovulation. The pain is caused by growth of the dominant follicle within the ovary, or rupture of the follicle and subsequent spillage of follicular fluid and blood into the peritoneal space. The pain is fairly sharp and is felt on the right or left side of the pelvis. It generally lasts a few hours to 2 days. Mittelschmerz is not related to menstrual flow, pain during intercourse, or pain associated with menstruation.

A client who has been seen in the clinic has been diagnosed with endometriosis and asks the nurse to describe this condition. Which is the best response for the nurse to provide?

• Endometriosis is pain that occurs during ovulation.

• Endometriosis causes the cessation of menstruation.

• Endometriosis is also known as primary dysmenorrhea.

• Endometriosis is the presence of tissue outside the uterus that resembles the lining of the uterus.

Answer explanation

Endometriosis is defined as the presence of tissue outside the uterus that resembles the endometrium in structure and function. The response of this tissue to the stimulation of estrogen and progesterone during the menstrual cycle is identical to that of the endometrium. Primary dysmenorrhea refers to menstrual pain without identified pathology. Mittelschmerz refers to pelvic pain that occurs midway between menstrual periods. Amenorrhea is the cessation of menstruation for a period of at least 3 cycles or 6 months in a woman who has established a pattern of menstruation. It can result from a variety of causes.

The nurse is teaching an adolescent female about menstruation. Which statements if made by the adolescent female demonstrate a need for further teaching? Select all that apply.

• "The average duration of menstruation is 3 days."

• "Menstruation typically begins 14 days after ovulation."

• "The menstrual cycle prepares the uterus for pregnancy."

• "I will lose about 40 mL of blood during my menstrual period."

• The day of ovulation is counted as the first day of the menstrual cycle."

Answer explanation

First menstruation is termed menarche. The average duration of menstruation is 5 days. Day 1 of menstruation is the first day of the menstrual cycle. Menstruation typically begins 14 days after ovulation. The menstrual cycle prepares the uterine lining for pregnancy implantation. During a menstrual period, a woman loses about 40 mL of blood.

A client taking metronidazole for the treatment of Trichomonas vaginalis calls the nurse employed in the primary health care provider's office concerned because of a feeling of tingling and numbness in the extremities. Which instructions would the nurse provide to the client?

• Increase fluid intake.

• Discontinue the medication.

• Numbness and tingling of the extremities is a harmless side effect.

• Report to the clinic to see the primary health care provider immediately.

Answer explanation

Metronidazole should be monitored for neurotoxicity. The primary health care provider should be seen if numbness or tingling occurs. Increasing fluid intake, discontinuing the medication, or indicating this is a harmless side effect are inappropriate options.

The nurse is monitoring a client with a C5 spinal cord injury for spinal shock. Which findings would be associated with spinal shock in this client? Select all that apply.

• Bowel sounds are absent.

• The client's abdomen is distended.

• Respiratory excursion is diminished.

• The blood pressure rises when the client sits up.

• Accessory muscles of respiration are areflexic.

Answer explanation

During the period of areflexia that characterizes spinal shock, the blood pressure may fall when the client sits up. The bowel and bladder often become flaccid, may become distended, and fail to empty spontaneously. Bowel sounds would be absent. Accessory muscles of respiration may become areflexic as well, diminishing respiratory excursion and oxygenation.

A client has been taking prednisone for 3 years. She is scheduled for abdominal hysterectomy. The nurse plans care realizing that postoperatively the client is at risk for which conditions? Select all that apply.

• Hypoglycemia

• Increased risk for dehiscence

• Excessive bleeding at the surgical incision

• Increased likelihood of surgical site infection

• Very early wound healing, causing excessive scarring

Answer explanation

Chronic use of glucocorticoids, such as prednisone, increases the risk of surgical site infections and the potential for dehiscence. Wound healing may be slow. Glucocorticoids increase the blood glucose. Excessive bleeding is not associated with glucocorticoids.