Spinal Cord Injuries Flashcards
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia?
Support selection of a high-protein diet.
Discuss options for sexuality and fertility.
Assist in planning a prescribed bowel program.
Use quad coughing to strengthen cough efforts.
ANS: C
Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock?
Hyperactive reflex activity below the level of injury
Involuntary, spastic movements of the arms and legs
Hypotension, bradycardia, and warm, pink extremities
Lack of sensation or movement below the level of injury
ANS: C
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 left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care?
Assessment of the patient for right arm weakness
Assessment of the patient for increased right leg pain
Positioning the patient’s left leg when turning the patient Teaching the patient to look at the right leg to verify its position
ANS: C
The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost on the patient’s right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.
The nurse will explain to the patient who has a T2 spinal cord transection injury that use of the shoulders will be limited. function of both arms should be retained. total loss of respiratory function may occur. tachycardia is common with this type of injury.
ANS: B
The patient with a T2 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 T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care?
Teach the patient the Credé method.
Instruct the patient how to self-catheterize.
Catheterize for residual urine after voiding.
Assist the patient to the toilet every 2 hours.
ANS: B
Because the patient’s 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 Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient’s incontinence.
When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to
drive a car with powered hand controls.
push a manual wheelchair on a flat surface.
turn and reposition independently when in bed. transfer independently to and from a wheelchair.
ANS: B
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse “I want to be transferred to a hospital where the nurses know what they are doing!” Which action by the nurse is best?
Clarify that abusive language will not be tolerated.
Request that the patient provide input for the plan of care.
Perform care without responding to the patient’s comments.
Reassure the patient about the competence of the nursing staff.
ANS: B
The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient’s input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient’s anger. Ignoring the patient’s comments will increase the patient’s anger and sense of helplessness.
A 38-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 unassisted during rehabilitation. The most appropriate action by the nurse at this time is to
a. remind the patient about the importance of independence in daily activities.
b. tell the spouse to stop because the patient is able to perform activities independently.
c. develop a plan to increase the patient’s independence in consultation with the patient and the
spouse.
d. recognize that it is important for the spouse to be involved in the patient’s care and encourage that
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 patient’s 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.
Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury?
Cardiac monitoring for bradycardia
Assessment of respiratory rate and effort
Application of pneumatic compression devices to legs
Administration of methylprednisolone (Solu-Medrol) infusion
ANS: B
Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient’s respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.
A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to
administer humidified oxygen by mask.
suction the patient’s mouth and nasopharynx.
push upward on the epigastric area as the patient coughs. encourage incentive spirometry every 2 hours during the day.
ANS: B
Because 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 patient’s 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 nurse’s first action.
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, “I have a pounding headache and I feel sick to my stomach.” Which action should the nurse take first? Check for a fecal impaction. Give the prescribed analgesic. Assess the blood pressure (BP). 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 patient’s 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. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.
A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action?
The patient has new onset weakness of both legs.
The patient complains of chronic severe back pain.
The patient starts to cry and says, “I feel hopeless.”
The patient expresses anxiety about having surgery.
ANS: A
The new onset of symptoms indicates cord compression, which is 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.
Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care?
Catheterize patient every 3 to 4 hours.
Assist patient to ambulate several times daily.
Administer medications to reduce bladder spasm.
Stabilize the neck when repositioning the patient.
ANS: A
Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.
Which finding in a patient with a spinal cord tumor is most important for the nurse to report to the health care provider? Back pain that increases with coughing
Depression about the diagnosis of a tumor
Decreasing sensation and ability to move the legs
Anxiety about scheduled surgery to remove the tumor
ANS: C
Decreasing sensation and leg movement indicates spinal cord compression, an emergency that will require rapid action (such as surgery) to prevent paralysis. The other findings will also require nursing action but are not emergencies.
A 33-year-old patient with a T4 spinal cord injury asks the nurse whether he will be able to be sexually active. Which initial response by the nurse is best?
Reflex erections frequently occur, but orgasm may not be possible.
Sildenafil (Viagra) is used by many patients with spinal cord injury.
Multiple options are available to maintain sexuality after spinal cord injury.
Penile injection, prostheses, or vacuum suction devices are possible options.
ANS: C
Although sexuality will be changed by the patient’s 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 patient’s individual feelings about sexuality.
