Exam 5 Flashcards
Spinal Cord Injury
A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?
A. allodynia
B. hyperalgesia
C. nociceptive
D. idiopathic
A. allodynia
Allodynia is a type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus. Hyperalgesia is a type of neurogenic pain whereby clients experience an increased response to a painful stimulus. Nociceptive pain is detected by specialized sensory nerves located throughout the soft tissues and is not neurogenic. Idiopathic pain has no apparent underlying cause and is not neurogenic.
Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.
A. Eating
B. Breathing
C. Ambulating
D. Transferring to a wheelchair
E. Writing
A, B, D, E
Eating, breathing, transferring to a wheelchair, and writing are functional abilities for those with a T4 injury. Ambulation can be performed independently by a client with an injury at T11–S5 injury.
The nurse suspects a client with a spinal cord injury is developing autonomic dysreflexia. Which assessment finding(s) confirm the development of this complication? Select all that apply.
A. blood pressure 180/98 mm Hg
B. skin covered with macular rash
C. pulse rate of 49 beats/min
D. reports of a pounding headache
E. cold, cyanotic lower legs
A, C, D
Autonomic dysreflexia represents an acute episode of exaggerated sympathetic reflex responses that occur in clients with injuries at T6 and above, in which central nervous system control of spinal reflexes is lost. It is characterized by hypertension (blood pressure 180/98), skin pallor, vagal slowing of the heart rate (pulse rate 49 beats/min), and headache ranging from dull to severe and pounding.
A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse’s care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client?
A. Pneumonia, pulmonary embolism, and sepsis
B. Cardiac tamponade, hypoxia, and malnutrition
C. Oxygen toxicity in paralytic ileus and electrolyte imbalances
D. Seizures, osteomyelitis, and urinary tract infections
A. Pneumonia, pulmonary embolism, and sepsis
he nurse is assisting the client with assisted coughing to prevent pneumonia. Pulmonary infections are managed and prevented by frequent coughing, turning, and deep breathing exercises and chest physiotherapy; aggressive respiratory care and suctioning of the airway if a tracheostomy is present; assisted coughing as needed; and adequate hydration. Low-dose anticoagulation therapy usually is initiated to prevent DVT (deep vein thrombosis) and PE (pulmonary embolism), along with the use of anti-embolism stockings or sequential pneumatic compression devices (SCDs). Pressure injuries have the potential complication of sepsis, osteomyelitis, and fistulas. All of the other listed causes may occur in clients with SCI but are not the main causes of death. The interventions discussed above directly assist in the prevention of pneumonia, pulmonary embolism osteomyelitis and sepsis.
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.
A. Young age
B. Male gender
C. Older adult
D. Substance use disorder
E. Low-income community
A, B, D
A client with a spinal cord injury at T8 would likely retain normal motor and somatosensory function of their:
A. Arms
B. Bowels
C. Bladder
D. Perineal musculature
A. Arms
A spinal cord injury at T8 would likely allow the client to retain normal function of the upper extremities, while innervations governing the function of the bowels, bladder, and perineum would be severed.
The nurse caring for a client diagnosed with a spinal cord injury notes early signs and symptoms of atrophy. Which of the following is the most appropriate nursing action?
A. Limit the amount of assistance provided with ADLs.
B. Collaborate with the physical therapist and immobilize the client’s extremities temporarily.
C. Increase the frequency of passive range-of-motion (ROM) exercises.
D. Educate the client about the importance of frequent position changes.
C. Increase the frequency of passive range-of-motion (ROM) exercises.
To prevent atrophy, ROM exercises must be done at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.
A client who has experienced a spinal cord injury has an ipsilateral loss of voluntary motor function and a contralateral loss of pain and temperature sensation. Based on these symptoms, which classification of spinal cord injury does the client have?
A. Paraplegia
B. Tetraplegia
C. Anterior Cord Syndrome
D. Brown Sequard
D. Brown Sequard
A condition called Brown-Sequard syndrome results from damage to a hemisection of the anterior and posterior cord. The effect is an ipsilateral loss of voluntary motor function from the corticospinal tract and proprioception loss with a contralateral loss of pain and temperature sensation from the lateral spinothalamic tracts for all levels below the lesion.
A neurologic nurse is explaining the structure and function of motor units to a client who has a spinal cord injury. The nurse should describe which components of a motor unit? Select all that apply.
A. Meninges
B. Neuromuscular junction
C. Skeletal muscle
D. Lower motor neuron
E. Cerebrospinal fluid
B, C, D
The motor unit consists of the LMN, the neuromuscular junction, and the skeletal muscle fibers that the nerve innervates. The meninges and CSF are not components of a motor unit.
A client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of their urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team’s decision regarding this intervention?
A. Urinary retention can have serious consequences in clients with SCIs.
B. Urinary function is permanently lost following an SCI.
C. Urinary catheters should not remain in place for more than 7 days.
D. Overuse of urinary catheters can exacerbate nerve damage.
A. Urinary retention can have serious consequences in clients with SCIs
Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.
The nurse is suctioning a client with a C3 spinal cord injury when the client’s heart rate drops from 86 bpm to 42 bpm. What intervention does the nurse understand should be provided prior to suctioning to prevent this vasovagal response from occurring?
A. Administer a saline bolus of 500 mL prior to suctioning.
B. Lower the head of the bed to a flat position prior to suctioning.
C. Administer atropine 1.0 mg prior to suctioning.
D. Hyperoxygenate prior to suctioning.
D. Hyperoxygenate prior to suctioning.
The vagus nerve exerts a continuous inhibitory effect on heart rate. Vagal stimulation that causes a marked bradycardia is called the vasovagal response. Preventive measures, such as hyperoxygenation before, during, and after suctioning, are advised.
At which of the following spinal cord injury levels does the client have full head and neck control?
A. C5
B. C4
C. C3
D. C2
A. C5
At the level of C5, the client should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the client will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the client will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?
A. Diarrhea
B. Placing the client in a sitting position
C. Placing a blanket over the client D. Voiding
C. Placing a blanket over the client
An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?
A. “I will change the vest liner periodically.”
B. “If a pin becomes detached, I’ll notify the surgeon.”
C. “I can apply powder under the liner to help with sweating.”
D. “I’ll check under the liner for blisters and redness.”
C. “I can apply powder under the liner to help with sweating.”
Powder is not used inside the vest because it may contribute to the development of pressure injuries. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide?
A. Elevate the head of the bed.
B. Disimpact the stool from the anal vault.
C. Insert an indwelling catheter.
D. Give the client some orange juice and sugar.
A. Elevate the head of the bed.
Autonomic dysreflexia is a clinical emergency, and without prompt and adequate treatment, convulsions, loss of consciousness, and even death can occur. The major components of treatment include monitoring blood pressure while removing or correcting the initiating cause or stimulus. The person should be placed in an upright position, and all support hose or binders should be removed to promote venous pooling of blood and reduce venous return.
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
A. Absence of reflexes along with flaccid extremities
B. Positive Babinski’s reflex along with spastic extremities
C. Hyperreflexia along with spastic extremities
D. Spasticity of all four extremities
A. Absence of reflexes along with flaccid extremities
During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski’s reflex, hyperreflexia, and spasticity of all four extremities.
Which complication of spinal cord injury is the most preventable in a paraplegic client?
A. Skin breakdown
B. Muscle atrophy
C. Deep vein thrombosis
D. Autonomic dysreflexia
A. Skin breakdown
The lack of sensory warning mechanisms and voluntary motor ability below the level of injury, coupled with circulatory changes, places the person with spinal cord injury at major risk for disruption of skin integrity. Significant factors associated with disruption of skin integrity are pressure, shearing forces, and localized trauma and irritation. Relieving pressure, allowing adequate circulation to the skin, and inspecting the skin are primary ways of maintaining skin integrity. Of all the complications after spinal cord injury, skin breakdown is the most preventable.
For a client with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
A. So that the client will not have a respiratory arrest
B. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
C. To increase cerebral perfusion pressure
D. To prevent secondary brain injury
B. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
A nurse is caring for a client who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?
A. Tachycardia and hypotension
B. Bradycardia and hypertension
C. Tachycardia and hypertension
D. Bradycardia and hypotension
B. Bradycardia and hypertension
Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (“goose bumps”), bradycardia, and hypertension. It may occur in cord lesions above T6 after spinal shock has resolved.
A client sustained an acceleration-deceleration injury during a motor vehicle accident. Which finding(s) should the nurse expect to assess in this client? Select all that apply.
A. neck pain
B. headache
C. unstable gait
D. dizziness
E. elevated blood pressure
A, B, C, D
An acceleration-deceleration injury affects the soft tissues (nerve tissue, cervical disks, tendons, muscles, and ligaments) of the cervical spine after sudden hyperextension and flexion of the head. Because the neck is flexed and hyperextended, neck pain will occur along with a headache and dizziness. An unstable gait occurs because of an injury to the head and neck. Elevated blood pressure is not a manifestation associated with this type of injury.
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.
A. Hypertension
B. Tachycardia
C. Fever
D. Diaphoresis
E. Nasal congestion
A, D, E
Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the client may be diaphoretic, a fever does not accompany this condition.
Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?
A. Examine the skin for any area of pressure or irritation.
B. Examine the rectum for a fecal mass.
C. Empty the bladder immediately. D. Raise the head of the bed and place the client in a sitting position.
D. Raise the head of the bed and place the client in a sitting position.
The head of the bed is raised and the client is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
A client with a C7 spinal cord fracture informs the nurse, “My head is killing me!” The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?
A. Place the client in a sitting position.
B. Call the health care provider.
C. Assess the client for a full bladder. D. Assess the client for a fecal impaction.
A. Place the client in a sitting position.
Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among clients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The client is placed immediately in a sitting position to lower blood pressure.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
A. Administering zolpidem tartrate (Ambien)
B. Assessing laboratory test results as ordered
C. Placing the client in Trendelenburg’s position
D. Monitoring the patency of an indwelling urinary catheter
D. Monitoring the patency of an indwelling urinary catheter
A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg’s position can’t prevent autonomic dysreflexia.
