A nurse is assessing a client who has a herniated cervical intervertebral disc. Which of the following findings should the nurse expect? Select all that apply.
Tingling in the arms
Shoulder pain
Muscle spasms
Stiff neck
Low back pain
Correct Answer : A,B,C,D
Choice A reason: Tingling in the arms can occur due to nerve compression caused by the herniated disc. This is a common symptom known as radicular pain, which can radiate from the neck down to the arms and hands.
Choice B reason: Shoulder pain is another expected finding, as the nerves affected by a cervical herniated disc can cause pain to radiate into the shoulders.
Choice C reason: Muscle spasms may be a reflexive response to the pain and inflammation caused by the herniated disc, as the body attempts to stabilize the affected area.
Choice D reason: A stiff neck can result from the muscle tension and reduced range of motion due to the pain and inflammation associated with a herniated cervical disc.
Choice E reason: Low back pain is not typically associated with a herniated cervical disc, as cervical discs are located in the neck region. Low back pain would be more indicative of a lumbar spine issue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Weighing the client daily is important for monitoring fluid balance but is not the most immediate action to prevent an Addisonian crisis.
Choice B reason: Restricting fluid intake is not appropriate for a client at risk for Addisonian crisis, as they may require increased fluids to prevent dehydration.
Choice C reason: This is the correct action. Clients with Addison's disease require corticosteroids to replace the hormones that their adrenal glands are not producing.
Choice D reason: Providing a low carbohydrate diet is not relevant to the prevention of an Addisonian crisis.
Correct Answer is C
Explanation
The correct answer is: c. Prepare the client for intubation.
Choice A: Prepare to administer a vasopressor
Reason: Vasopressors are typically used to manage hypotension (low blood pressure) and are not a standard treatment for myasthenic crisis. Myasthenic crisis primarily involves respiratory muscle weakness, which can lead to respiratory failure, rather than issues with blood pressure.
Choice B: Administer an anticholinesterase medication
Reason: While anticholinesterase medications like pyridostigmine are used to manage myasthenia gravis, they are generally not recommended during a myasthenic crisis. During a crisis, the focus is on stabilizing the patient, often requiring more immediate interventions such as intubation and mechanical ventilation.
Choice C: Prepare the client for intubation
Reason: Intubation is a critical intervention in a myasthenic crisis due to the risk of respiratory failure. The crisis is characterized by severe muscle weakness, including the muscles that control breathing. Intubation ensures that the airway is protected and that the patient can receive adequate ventilation.
Choice D: Instruct the client to perform pursed lip breathing
Reason: Pursed lip breathing is a technique used to improve breathing efficiency in conditions like chronic obstructive pulmonary disease (COPD). However, it is not appropriate for managing a myasthenic crisis, where the primary issue is severe muscle weakness leading to respiratory failure.
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