Spinal Cord Injury NCLEX – Flashcards
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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
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Correct Answer(s): D Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
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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
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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.
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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
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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.
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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
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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.
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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
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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
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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
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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 peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs.
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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
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Correct Answer(s): B the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.
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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 asssist control ventilation
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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 pinal shock resolves.
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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
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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.
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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
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Correct Answer(s): D Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygentation and ventilation.
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A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. the presence of hyperactive reflex activity below the level of the injury. d. flaccid paralysis and lack of sensation below the level of the injury.
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Correct Answer(s): D Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.
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When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to a. administer oxygen at 7 to 9 L/min with a face mask. b. place the hands on the epigastric area and push upward when the patient coughs. c. encourage the patient to use an incentive spirometer every 2 hours during the day. d. suction the patient's oral and pharyngeal airway.
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Correct Answer(s): B Rationale: The nurse has identified that the cough effort is poor, so 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, and oxygen will not help expel respiratory secretions. 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.
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A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's 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.
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Correct Answer(s): B Rationale: 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. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.
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The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess a. blood pressure and heart rate. b. respiratory effort and O2 saturation. c. motor and sensory function of the legs. d. bowel sounds and abdominal distension.
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Correct Answer(s): C Rationale: The purpose of methylprednisolone administration is to help preserve neurologic function; therefore, the nurse will assess this patient for lower-extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.
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A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding
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Correct Answer(s): A Rationale: 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 a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
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A patient with a history of a T2 spinal cord 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. Notify the patient's health care provider. b. Check the blood pressure (BP). c. Give the ordered antiemetic. d. Assess for a fecal impaction.
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Correct Answer(s): B Rationale: 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 causing the symptoms, including hypertension. 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. 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.
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The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An appropriate patient outcome is a. transfers independently to a wheelchair. b. drives a car with powered hand controls. c. turns and repositions self independently when in bed. d. pushes a manual wheelchair on flat, smooth surfaces.
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Correct Answer(s): D Rationale: 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.
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A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the injury and becomes verbally abusive to the nurses and other staff. The patient demands to be transferred to another hospital, where "they know what they are doing." The best response by the nurse to the patient's behavior is to a. ask for the patient's input into the plan for care. b. clarify that abusive behavior will not be tolerated. c. reassure the patient that the anger will pass and rehabilitation will then progress. d. ignore the patient's anger and continue to perform needed assessments and care.
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Correct Answer(s): A Rationale: 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 patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Refusal to acknowledge the patient's anger by telling the patient that the anger is just a phase is inappropriate. Continuing to perform needed assessments and care is appropriate, but the nurse should seek the patient's input into what care is needed.
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A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have always had a very active sex life, and I am worried that she may leave me if I cannot function sexually." The most appropriate response by the nurse to the patient's comment is to a. advise the patient to talk to his wife to determine how she feels about his sexual function. b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with spinal cord injury. c. inform the patient that most patients with upper motor neuron injuries have reflex erections. d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling.
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Correct Answer(s): D Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal cord injury and should be handled by someone with expertise in sexual counseling. Although the patient should discuss these issues with his wife, open communication about this issue may be difficult without the assistance of a counselor. Sildenafil does assist with erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined solely by the ability to have an erection. Reflex erections are common after upper motor neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
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A 25-year-old patient has returned home following extensive rehabilitation for a C8 spinal cord injury. The home care nurse visits and notices that the patient's spouse and parents are performing many of the activities of daily living (ADLs) that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the family members that the patient can perform ADLs independently. b. remind the patient about the importance of independence in daily activities. c. recognize that it is important for the patient's family to be involved in the patient's care and support their activities. d. develop a plan to increase the patient's independence in consultation with the with the patient, spouse, and parents.
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Correct Answer((s): D Rationale: 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 family that the patient can perform ADLs independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the family members. Supporting the activities of the spouse and parents will lead to ongoing dependency by the patient.
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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. Continuous cardiac monitoring for bradycardia b. Administration of methylprednisolone (Solu-Medrol) infusion c. Assessment of respiratory rate and depth d. Application of pneumatic compression devices to both legs
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Correct Answer(s): C Rationale: 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. The other actions are also appropriate but are not as important as assessment of respiratory effort.
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In which order will the nurse perform the following actions when caring for a patient with possible cervical spinal cord trauma who is admitted to the emergency department? a. Administer O2 using a non-rebreathing mask. b. Monitor cardiac rhythm and blood pressure. c. Immobilize the patient's head, neck, and spine. d. Transfer the patient to radiology for spinal CT.
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Correct Answer(s): C, A, B, D Rationale: The first action should be to prevent further injury by stabilizing the patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, continuous monitoring of heart rhythm and BP is indicated. CT scan to determine the extent and level of injury is needed once initial assessment and stabilization is accomplished.
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The nurse is caring for a man who has experienced a spinal cord injury. Throughout his recovery, the client expects to gain control of his bowels. The nurse's best response to this client would be which of the following? a. "Over time, the nerve fibers will regrow new tracts, and you can have bowel movements again." b. "Wearing an undergarment will become more comfortable over time." c "Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact." d "It is not going to happen. Your nerve cells are too damaged."
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Correct Answer(s: ) C Having a bowel movement is a spinal reflex requiring intact nerve fibers. Yours are not intact The act of defecation is a spinal reflex involving the parasympathetic nerve fibers. Normally, the external anal sphincter is maintained in a state of tonic contraction. With a spinal cord injury, the client no longer has this nervous system control and is often incontinent.
