CHAPTER 61: SCI and Neurogenic Shock Flashcards
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia? A) Tachycardia B) Hypotension C) Hot, dry skin D) Throbbing headache
Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?
A) Risk for impairment of tissue integrity caused by paralysis
B) Altered patterns of urinary elimination caused by quadriplegia
C) Altered family and individual coping caused by the extent of trauma
D) Ineffective airway clearance caused by high cervical spinal cord injury
Correct Answer(s): D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.
Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?
A) Headache and rising blood pressure
B) Irregular respirations and shortness of breath
C) Decreased level of consciousness or hallucinations
D) Abdominal distention and absence of bowel sounds
Correct Answer(s): A Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient’s upper airway
D) Placement of the patient in the Trendelenburg position
Correct Answer(s): A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.
Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury? select all that apply. a. vital sign b. romberg test c. plantar reflexes d. bilatereal hand grasps e. description of trauma
Correct Answer (s): a, c, d, e
the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma.
Romberg test must be performed while standing therefore not suitable for unstable patient
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia?
a. Assist with selection of a high protein diet.
b. Use quad coughing to assist cough effort.
c. Discuss options for sexuality and fertility.
d. Teach the purpose of a prescribed bowel program.
ANS: D
Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. hyperactive reflex activity below the level of the injury.
d. lack of movement or sensation below the level of the injury.
ANS: A
Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
A patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Squard syndrome. Which nursing action 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 patients right leg when turning the patient
d. Teaching the patient to look at the left leg to verify its position
ANS: C
The patient with Brown-Squard 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 patients 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.
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patients arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury.
ANS: B
The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care?
a. Educate on the use of the Cred 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.
ANS: B
Because the patients 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 Cred 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 patients incontinence.
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which reaction by the nurse is best?
a. Ask for the patients input into the plan for care.
b. Clarify that abusive behavior will not be tolerated.
c. Reassure the patient about the competence of the nursing staff.
d. Continue to perform care without responding to the patients comments.
ANS: A
The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patients input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patients anger. Ignoring the patients comments will increase the patients anger and sense of helplessness.
After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to
a. tell the spouse that the patient can perform activities independently.
b. remind the patient about the importance of independence in daily activities.
c. develop a plan to increase the patients independence in consultation with the patient and the spouse.
d. recognize that it is important for the spouse to be involved in the patients care and support the spouses participation.
ANS: C
The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patients ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
A patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient? A. poor propricopetor in the legs B. poor peristalsis in the intestines C. Absent gag and blinking reflexes D. Absent bladder fulness sensation
Answer is B
A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristaltic action in the intestines but should retaine the ability to sense bladder fulness and the position of the legs.
The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication? A. record pt baseline weight B. adminster PPI( proton pump inhibitor) C. Check the hear rate for bradycardia D. suction the patient's oropharynx
Correct Answer(s): B the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.
A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves? A. opoiod analgesic Iv for foot pain B. able to blance in sitting position C. unresponsive quadriceps muscle D. requites assist control ventilation
Correct Answer(s) : C during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the spinal shock resolves.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action 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 (Solu-Medrol) infusion
ANS: A
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patients respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort.
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to
a. suction the patients oral and pharyngeal airway.
b. administer oxygen at 7 to 9 L/min with a face mask.
c. place the hands on the epigastric area and push upward when the patient coughs.
d. encourage the patient to use an incentive spirometer every 2 hours during the day.
ANS: C
Since the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patients ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurses first action.
To evaluate the effectiveness of IV methylprednisolone (Solu-Medrol) given to a patient with a T4 spinal cord injury, which information is most important for the nurse to obtain?
a. Leg strength and sensation
b. Skin temperature and color
c. Blood pressure and apical heart rate
d. Respiratory effort and O2 saturation
ANS: A
The purpose of methylprednisolone administration is to help preserve motor function and sensation. Therefore the nurse will assess this patient for lower extremity function. The other data also will be collected by the nurse, but they do not reflect the effectiveness of the methylprednisolone.
A patient with a history of a T2 spinal cord injury tells the nurse, I feel awful today. My head is throbbing, and I feel sick to my stomach. Which action should the nurse take first?
a. Assess for a fecal impaction.
b. Give the prescribed antiemetic.
c. Check the blood pressure (BP).
d. Notify the health care provider.
ANS: C
The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patients health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.
The nurse is assessing a patient who is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
a. The patient has new onset weakness of both legs.
b. The patient complains of chronic severe back pain.
c. The patient starts to cry and says, I feel hopeless.
d. The patient expresses anxiety about having surgery
ANS: A
The new onset of symptoms indicates cord compression, an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.
A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best?
a. Reflex erections frequently occur, but orgasm may not be possible.
b. Sildenafil (Viagra) is used by many patients with spinal cord injury.
c. Multiple options are available to maintain sexuality after spinal cord injury.
d. Penile injection, prostheses, or vacuum suction devices are possible options.
ANS: C
Although sexuality will be changed by the patients spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patients individual feelings about sexuality.
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)?
a. Urinary catheter care
b. Nasogastric (NG) tube feeding
c. Continuous cardiac monitoring
d. Avoidance of cool room temperature
e. Administration of H2 receptor blockers
ANS: A, C, D, E
The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication but can be avoided through the use of the H2 receptor blockers such as famotidine.
In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________
a. Infuse normal saline at 150 mL/hr.
b. Monitor cardiac rhythm and blood pressure.
c. Administer O2 using a non-rebreather mask.
d. Transfer the patient to radiology for spinal computed tomography (CT).
e. Immobilize the patients head, neck, and spine.
E, C, B, A, D
The first action should be to prevent further injury by stabilizing the patients spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
A female nurse is injured in an automobile accident and suffers acute compresssion of the anterior apinal cord at T8-10 Which nursing rols is a potential source of employment for the patients after completing rehabilitation ? A. Certified nurse practioner B. Community health nursing C. Hospital case mangement D. Inpatient behavioral health
Correct C. Hospital case management(s)
the nurse in most likely to have an anterior cord syndrome resulting in the loss of neuromuscular and pain and temp sensation below t8. Pt will have full use of upper extremities , upper back, and resp muscles.thus she will be in a wheel chair.
A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation? A. increased bone density loss B. higher tisk for tissue hpoxia C. vasomotor compensation lost D. Weakness of thoracic muscles
Correct Answer(s): D Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygenation and ventilation.
