Exam 3: Spinal Cord Injury NCLEX Questions

Exam 3: Spinal Cord Injury NCLEX Questions

5.0 (1 review) Students also studied Terms in this set (52) Science MedicineNursing Save Spinal Cord Injury NCLEX 26 terms ET0003Preview Spinal Cord Injury NCLEX Questions...53 terms Maria_Coronado22 Preview Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview NCLEX 100 term akr 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