SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST
VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS WITH
RATIONALES|AGRADE
. A patient with spinal cord injury is experiencing severe neurologic deficits. What
is the most likely mechanism of injury for this patient?
a. Compression
b. Hyperextension
c. Flexion-rotation
d. Extension-rotation – ANSWER- c. Flexion-rotation
- 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- a. L1-2 - A patient with a T4 spinal cord injury experiences neurogenic shock as a result
of sympathetic nervous system dysfunction. What would the nurse recognize as
characteristic of this condition?
a. Tachycardia
b. Hypotension
c. Increased cardiac output
d. Peripheral vasoconstriction – ANSWER- b. Hypotension - A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse
he must have the flu because he has a bad headache and nausea. The nurse’s first
priority is to
a. call the HCP.
b. check the patient’s temperature.
c. take the patient’s blood pressure.
d. elevate the head of the bed to 90 degrees. – ANSWER- c. take the patient’s blood
pressure.
- For a 65-year-old woman who has lived with a T1 spinal cord injury for 20
years, which health teaching instructions should the nurse emphasize?
a. A mammogram is needed every year.
b. Bladder function tends to improve with age.
c. Heart disease is not common in people with spinal cord injury.
d. As a person ages, the need to change body position is less important. –
ANSWER- a. A mammogram is needed every year. - The most common early symptom of a spinal cord tumor is
a. urinary incontinence.
b. back pain that worsens with activity.
c. paralysis below the level of involvement.
d. impaired sensation of pain, temperature, and light touch. – ANSWER- b. back
pain that worsens with activity. - During assessment of the patient with trigeminal neuralgia, the nurse should
(select all that apply)
a. inspect all aspects of the mouth and teeth.
b. assess the gag reflex and respiratory rate and depth.
c. lightly palpate the affected side of the face for edema.
d. test for temperature and sensation perception on the face.
e. ask the patient to describe factors that initiate an episode. – ANSWER- a. inspect
all aspects of the mouth and teeth.
d. test for temperature and sensation perception on the face.
e. ask the patient to describe factors that initiate an episode. - During routine assessment of a patient with Guillain-Barré syndrome, the nurse
finds the patient is short of breath. The patient’s respiratory distress is caused by
a. elevated protein in the CSF.
b. immobility resulting from ascending paralysis.
c. degeneration of motor neurons in the brainstem and spinal cord.
d. paralysis ascending to the nerves that stimulate the thoracic area – ANSWER- d.
paralysis ascending to the nerves that stimulate the thoracic area - A nurse is caring for a patient newly diagnosed with chronic inflammatory
demyelinating polyneuropathy (CIDP). Which statement can the nurse accurately
use to teach the patient about CIDP?
a. “Corticosteroids have little effect on this disease.”
b. “Maintenance therapy will be needed to prevent relapse.”
c. “You will go into remission in approximately eight weeks.”
d. “You should be able to walk without help within three months.” – ANSWER- b.
“Maintenance therapy will be needed to prevent relapse.”
- A patient has a spinal cord injury at T4. Vital signs include falling blood
pressure with bradycardia. The nurse recognizes that the patient is experiencing
a. a relative hypervolemia.
b. an absolute hypovolemia.
c. neurogenic shock from low blood flow.
d. neurogenic shock from massive vasodilation. – ANSWER- d. neurogenic shock
from massive vasodilation.
A patient has been admitted to the hospital with a T3-level complete spinal cord
injury. The nurse has to plan the home-based rehabilitation for this patient. When
creating the care plan, the nurse considers the activities that the patient is able to do
independently. What activities should the nurse consider to make maximum use of
patient’s abilities? Select all that apply.
A. Independent self-care is possible.
B. Independent wheelchair mobility is possible.
C. Patient may be able to drive with hand controls.
D. Patient will be able to climb stairs independently.
E. Patient will be able to have effective coughing ability. – ANSWER- a, b, c
Rationale
The patient with a T3-level spinal cord injury will have full innervation of the
upper extremities, back, essential intrinsic muscles of the hands, full strength and
dexterity of grasp, decreased trunk stability, and decreased respiratory reserve.
Therefore, the patient may have the following potentials: full independence in selfcare and in a wheelchair, ability to drive a car with hand controls, independent
standing in a standing frame. Abdominal muscles are affected, so the ability to
cough is lost. The patient may also not be able to climb stars due to the injury.
A patient has been admitted to the hospital with a spinal cord injury. Following the
assessment, the health care provider concludes that the injury is above T12. What
signs and symptoms related to the gastrointestinal system would indicate an injury
above T12? Select all that apply.
A. The patient has an absence of bowel sounds.
B. There is excess gastric distention, and the stomach is hard.
C. The patient is constipated and is passing hard stools with straining.
D. The sensation of a full bowel is perceived by the patient, and fecal incontinence
is present.
E. The sensation of a full bowel is not perceived by the patient, and fecal
incontinence is present. – ANSWER- B, D
Rationale
An injury above T12 leads to development of a reflexic bowel, wherein nervous
interactions between the colon (large intestine) and the brain are interrupted. As a
result, the person may not feel the need to have a bowel movement. However, stool
is still building up in the rectum. The build-up triggers a reflex, causing the rectum
and colon to react, leading to a bowel movement without warning. When the
sensation of a full bowel is perceived by the patient and the patient has fecal
incontinence, it is a lower-level spinal cord injury (below T12). In spinal cord
injury, it is usually incontinence that occurs. When the injury is above T5, paralytic
ileus may be present and bowel sounds may be absent.
A nurse is assessing a patient with a T2-level spinal cord injury. The nurse notices
that there is a kink in the catheter, the bladder is distended, and the blood pressure
is 220/100 mm Hg. What nursing interventions would be appropriate for this
patient if the nurse suspects autonomic dysreflexia? Select all that apply.
A. Lower the head of the bed.
B. Monitor blood pressure regularly.
C. Make the patient lie flat on the bed.
D. Notify the primary health care provider.
E. Check for the presence of bowel impaction.
F. Remove the kink in the catheter and drain the bladder. – ANSWER- B. Monitor
blood pressure regularly.
D. Notify the primary health care provider.
E. Check for the presence of bowel impaction.
F. Remove the kink in the catheter and drain the bladder.
Rationale
A sudden rise in blood pressure for a spinal cord injury patient above the level of
T6 is generally indicative of autonomic dysreflexia. Nursing interventions in a
serious emergency like autonomic dysreflexia include notifying the primary health
care provider and determining the cause. The blood pressure should be regularly
monitored; administration of an alpha-adrenergic blocker or an arteriolar
vasodilator is required. Contractions of the rectum are also a cause; therefore, the