Exam 1: Spinal Cord Injury Questions

Exam 1: Spinal Cord Injury Questions

ScienceMedicineNursing danielle_white47 Save Spinal Cord Injury NCLEX 26 terms ET0003Preview ICP Nclex Questions, ICP NCLEX sty...120 terms Mariko_Roberts Preview Spinal Cord Injury Practice Question...62 terms LeMoyneFreeman Preview Sensor 34 terms Em The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response?

• hemodynamic changes related to tilt table positioning
• deteriorating myelin sheath
• distended large intestine
• crushed spinal cord

3

rationale:

Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia phenomenon.The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon.The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?

• bladder control
• nutritional intake
• quadriceps setting
• use of aids for ambulation

1

rationale:

Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; therefore nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, mobility usually is accomplished through the use of a wheelchair rather than ambulation.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?

• push-ups to strengthen arm muscles
• leg lifts to prevent hip contractures
• balancing exercises to promote equilibrium
• quadriceps-setting exercises to maintain muscle tone

1

rationale:

Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurologic control of the other activities.A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary?

• reflexes have been lost
• there is partial transection of the cord
• there is damage above the sixth thoracic vertebra
• flaccid paralysis of the lower extremities has occurred

3

rationale:

The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide?

• lower extremities are paralyzed
• upper extremities are paralyzed
• one side of the body is paralyzed
• both lower and upper extremities are paralyzed

1

rationale:

Both legs and generally the lower part of the body are paralyzed in paraplegia. There is no term to describe only upper extremities affected; all parts below an injury are affected. One side of the body paralyzed describes hemiplegia. The paralysis of both lower and upper extremities describes quadriplegia.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse?

• you shouldnt give up hope
• being incapacitated is difficult for you
• would you like to speak to a religious advisor
• have you talked to your family about your feelings

2

rationale:

The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem?

• dehydration
• skin breakdown
• electrolyte imbalances
• urinary tract infections

4

rationale:

Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?

• flaccid paralysis and numbness
• absence of sweating and pyrexia
• escalating tachycardia and shock
• paroxysmal hypertension and bradycardia

4

rationale:

When autonomic dysreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first?

• assess for the cause
• place the client in sitting position
• check the client for fecal impaction
• give an alpha blocker prophylactically

2

rationale:

Clients experiencing autonomic dysreflexia should immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure. The next step is to assess for the cause for autonomic dysreflexia. Fecal impaction and other colorectal complications are routinely assessed in the client. Alpha blockers can be given to treat recurrent autonomic dysreflexia.The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process?

• Removing the cervical spine collar
• Monitoring for autonomic dysreflexia
• Implementing the logrolling technique
• Administering the prescribed pain medication

3

rationale:

The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury. While monitoring and addressing pain is important, this is not the priority when transferring this client.The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation?

• place in a sitting position
• give nifedipine as prescribed
• examine for symptoms of pressure ulcers
• monitor blood pressure every 10-15 minutes

1

rationale:

Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.