week 3 - spinal cord injuries

Question 1

What are the common causes of spinal cord injuries (SCI)?

Answer 1

Motor vehicle accidents (MVA), falls, and sporting activities.

Question 2

What is the difference between primary and secondary spinal cord injury?

Answer 2

Primary injury occurs at the time of trauma (e.g., bone fragments damaging the cord), while secondary injury involves progressive damage over time (e.g., edema, hypoxia).

Question 3

List two complications that can result from spinal cord injuries.

Answer 3

Respiratory failure and autonomic dysreflexia.

Question 4

What immediate actions should you take for someone suspected of having a SCI?

Answer 4

Immobilize the head, neck, and spine; maintain a patent airway; monitor vital signs; and assess extremity movement and sensation.

Question 5

Define autonomic dysreflexia and its triggers.

Answer 5

Autonomic dysreflexia is a condition triggered by noxious stimuli (e.g., bladder distention) that causes severe hypertension due to simultaneous activation of sympathetic and parasympathetic systems.

Question 6

What nursing interventions are essential for managing a patient with increased intracranial pressure (ICP)?

Answer 6

Monitor neurological status, maintain head elevation, avoid sedatives that could depress respiration, and ensure a quiet environment.

Question 7

How can nurses promote resilience in spinal cord injury rehabilitation?

Answer 7

By involving patients in care planning, supporting self-efficacy, and using a strengths-based approach.

Question 8

What should be included in discharge teaching for a patient with autonomic dysreflexia?

Answer 8

Recognizing triggers, managing symptoms, and knowing when to seek emergency care.

Question 9

What assessment tool is used to evaluate a patient’s level of consciousness after a traumatic brain injury?

Answer 9

Glasgow Coma Scale (GCS).

Question 10

What are some common post-brain injury deficits?

Answer 10

Altered mental status, muscle weakness, spasticity, balance issues, sensory losses, and aphasia.

Question 11

Name two types of acquired brain injuries.

Answer 11

Traumatic and non-traumatic brain injuries.

Question 12

What is the priority nursing action for a patient experiencing signs of increased ICP?

Answer 12

Assess neurological status and implement interventions to reduce ICP.

Question 13

What is the significance of the Cushing’s triad in increased ICP?

Answer 13

It indicates a late sign of increased ICP, characterized by hypertension, bradycardia, and irregular respirations.

Question 14

What factors could indicate a risk for autonomic dysreflexia in a spinal cord injury patient?

Answer 14

Bladder distention, bowel impaction, skin irritation, and other noxious stimuli.

Question 15

What are key nursing considerations for managing respiratory complications in spinal cord injury patients?

Answer 15

Assess respiratory status, monitor ABGs, encourage deep breathing, and elevate the head of the bed.

Question 16

What is the primary injury in spinal cord injury (SCI)?

Answer 16

The initial mechanical forces that disrupt the spinal cord, causing contusion, laceration, or compression.

Question 17

What is autonomic dysreflexia?

Answer 17

a condition in patients with SCI, particularly above T6, characterized by severe hypertension due to simultaneous activation of the sympathetic and parasympathetic nervous systems.

Question 18

List three nursing interventions for managing a patient with SCI.

Answer 18

1) Maintain airway patency.
2) Monitor vital signs regularly.
3) Assess and manage bowel and bladder function.

Question 19

A patient with a suspected spinal cord injury arrives at the emergency department. Which of the following should the nurse do first?
A) Assess the patient’s airway.
B) Obtain a complete medical history.
C) Administer pain medication.
D) Perform a neurological exam.

Answer 19

A) Assess the patient’s airway.

Question 20

A nurse is monitoring a patient for signs of autonomic dysreflexia. Which of the following symptoms would indicate this condition?
A) Hypotension and bradycardia
B) Hypertension and severe headache
C) Tachycardia and fever
D) Decreased respiratory rate and drowsiness

Answer 20

B) Hypertension and severe headache.

Question 21

What is the most appropriate nursing action for a patient with increased intracranial pressure (ICP)?
A) Maintain a high protein diet.
B) Keep the head of the bed elevated at least 30 degrees.
C) Encourage the patient to cough regularly.
D) Use sedatives to ensure rest.

Answer 21

: B) Keep the head of the bed elevated at least 30 degrees

Question 22

Which of the following findings would the nurse expect in a patient with increased intracranial pressure?
A) Bradycardia and hypotension
B) Widening pulse pressure and increased blood pressure
C) Hypothermia and tachypnea
D) Decreased level of consciousness and hyperventilation

Answer 22

B) Widening pulse pressure and increased blood pressure.