SPINAL INJURY

Question 1

1.During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery?

a. L1-2
b. T6-7
c. T1-2
d. C7-8

Answer 1

A

Question 2

A patient with a T4 spinal cord injury experiences neurogenic shock as a result of SNS dysfunction. What would the nurse recognize as characteristic of this condition?

a. Tachycardia
b. Hypotension
c. Increased urine output
d. Peripheral vasoconstriction

Answer 2

B

Question 3

2.A patient with spinal cord injury is experiencing severe neurologic deficits. What is themostlikely mechanism of injury for this patient?

a. compression
b. hyperextension
c. flexion-rotation
d. extension-rotation

Answer 3

C

Question 4

A patient with a C7 SCI undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse’sfirstpriority is to

a. call the HCP
b. check the patient’s temperature
c. take the patient’s blood pressure
d. elevate the HOB to 90 degrees

Answer 4

C

Question 5

The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient’s discharge plan?

a. Keep a wrench close or attached to the vest.
b. Use the frame and vest to assist in positioning.
c. Clean around the pins using betadine swab sticks.
d. Loosen both sides of the vest to provide skin care

Answer 5

A

Question 6

The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful?

a. “I will perform self-catheterization at least six times per day.”
b. “A reflex erection may cause an unsafe drop in blood pressure.”
c. “If I develop a severe headache, I will lie down for 15 to 20 minutes.”
d. “I can avoid this problem by taking medications to prevent leg spasms.”

Answer 6

A

Question 7

A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse ismostappropriate?

a. Insert a rectal stimulant suppository.
b. Teach the patient to gradually increase intake of high-fiber foods.
c. Assess bowel movements for frequency, consistency, and volume.
d. Instruct the patient to avoid all caffeinated and carbonated beverages.

Answer 7

C

Question 8

The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?

a. Central cord syndrome
b. Spinal shock syndrome
c. Anterior cord syndrome
d. Brown-Séquard syndrome

Answer 8

B

Question 9

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?

a. Bradycardia
b. Hypertension
c. Neurogenic spasticity
d. Bounding pedal pulses

Answer 9

A

Question 10

When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has thehighestpriority?

a. Impaired urinary eliminationrelated totetraplegia
b. Risk for impaired tissue integrityrelated toparalysis
c. Disabled family copingrelated tothe extent of trauma
d. Ineffective airway clearancerelatedtocervical spinal cord injury

Answer 10

D

Question 11

Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible 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

Answer 11

A

Question 12

Which intervention should the nurse performfirstin the acute care of a patient with autonomic dysreflexia?

a. Urinary catheterization
b. Check for bowel impaction
c. Elevate the head of the bed
d. Administer intravenous hydralazine

Answer 12

C

Question 13

A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse’s priority when planning for rehabilitation?

a. Prevent urinary tract infection.
b. Monitor the patient every 15 minutes.
c. Encourage him to verbalize his feelings.
d. Teach him about using the gastrocolic reflex.

Answer 13

C

Question 14

A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse takefirst?

a. Administer the ordered acetaminophen.
b. Check the Foley tubing for kinks or obstruction.
c. Adjust the temperature in the client’s room.
d. Notify the health care provider about the change in status.

Answer 14

B

Question 15

The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void?Select all that apply.

a. Stroking the client’s inner thigh
b. Pulling on the client’s pubic hair
c. Initiating intermittent straight catheterization
d. Pouring warm water over the client’s perineum
e. Tapping the bladder to stimulate the detrusor muscle
f. Reminding the client to void in a urinal every hour while awake

Answer 15

A,B,D,E

Question 16

A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is theprioritynursing assessment?

a. Determine the level at which the client has intact sensation.
b. Assess the level at which the client has retained mobility.
c. Check blood pressure and pulse for signs of spinal shock.
d. Monitor respiratory effort and oxygen saturation level.

Answer 16

D

Question 17

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.

Answer 17

D

Question 18

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.

Answer 18

A

Question 19

20. 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.

Answer 19

B

Question 20

21.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

Answer 20

B

Question 21

22.When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to

a. transfer independently to a wheelchair.
b. drive a car with powered hand controls.
c. turn and reposition independently when in bed.
d. push a manual wheelchair on flat, smooth surfaces.

Answer 21

D

Question 22

23.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.

Answer 22

A

Question 23

24.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

Answer 23

A

Question 24

25.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

Answer 24

C

Question 25

26.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.

Answer 25

C

Question 26

27.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.

Answer 26

C

Question 27

28.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

Answer 27

A,C,D,E

Question 28

A 70 year old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock?

a. paraplegia with a flaccid paralysis
b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss
d. spastic tetraplegia with loss of pressure sensation

Answer 28

A

Question 29

30.What causes an initial SCI to result in complete cord damage?

a. edematous compression of the cord above the level of injury
b. continued trauma to the cord resulting from damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

Answer 29

C

Question 30

31.A patient is admitted to the ED with SCI at the level of T2. Which clinical finding is of most concern by the nurse?

a. SpO2 of 92%
b. heart rate of 42 bpm
c. BP of 88/60
d. loss of motor and sensory function in the arms and legs

Answer 30

B

Question 31

32.What is one indication for early surgical therapy of the patient with SCI?

a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical causes loss of respiratory function
d. evidence of continued compression of the cord is apparent

Answer 31

D