Exam 3: Spinal Cord Injury NCLEX Questions

Exam 3: Spinal Cord Injury NCLEX Questions

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CHA2: Neuro Dx/SCI/TIA

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julia 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?

• L1-2
• T6-7
• T1-2
• C7-8

a 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?

• Tachycardia
• Hypotension
• Increased urine output
• Peripheral vasoconstriction

b A patient with spinal cord injury is experiencing severe neurologic deficits. What is the most likely mechanism of injury for this patient?

• compression
• hyperextension
• flexion-rotation
• extension-rotation

c

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's first priority is to

• call the HCP
• check the patient's temperature
• take the patient's blood pressure
• elevate the HOB to 90 degrees

c 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?

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

a 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?

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

a 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 is most appropriate?

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

c 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?

• Central cord syndrome
• Spinal shock syndrome
• Anterior cord syndrome
• Brown-Séquard syndrome

b

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

• Bradycardia
• Hypertension
• Neurogenic spasticity
• Bounding pedal pulses

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

• Impaired urinary elimination related to tetraplegia
• Risk for impaired tissue integrity related to paralysis
• Disabled family coping related to the extent of trauma
• Ineffective airway clearance related to cervical spinal cord injury

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

• Headache and rising blood pressure
• Irregular respirations and shortness of breath
• Decreased level of consciousness or hallucinations
• Abdominal distention and absence of bowel sounds

a Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia?

• Urinary catheterization
• Check for bowel impaction
• Elevate the head of the bed
• Administer intravenous hydralazine

c 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?

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

c

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 take first?

• Administer the ordered acetaminophen.
• Check the Foley tubing for kinks or obstruction.
• Adjust the temperature in the client's room.
• Notify the health care provider about the change in status.

b 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.

• Stroking the client's inner thigh
• Pulling on the client's pubic hair
• Initiating intermittent straight catheterization
• Pouring warm water over the client's perineum
• Tapping the bladder to stimulate the detrusor muscle
• Reminding the client to void in a urinal every hour while awake

a b d e 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 the priority nursing assessment?

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

d 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?

• Assist with selection of a high protein diet.
• Use quad coughing to assist cough effort.
• Discuss options for sexuality and fertility.
• Teach the purpose of a prescribed bowel program.

d