NURS 221 NCLEX and Book Questions: Spinal Cord Injuries

NURS 221 NCLEX and Book Questions: Spinal Cord Injuries

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Exam 1: Spinal Cord Injury Questions...

30 terms danielle_white47 Preview Spinal 62 terms LeM 1. A client has been diagnosed with anterior cord syndrome. What does this syndrome represent?

• An upper motor neuron problem
• A lower motor neuron problem
• The best prognosis for recovery
• An incomplete cord injury

D

• Whiplash is a mild form of which primary injury to the spinal cord? A. Hyperflexion
• Axial loading
• Hyperextension
• Rotational

C

• Which region of the spine is most vulnerable to injury?
• Cervical
• Thoracic
• Lumbar
• Sacral

A

The events contributing to secondary injury of the spinal cord include which conditions? ( Select all that apply.)

• Ischemia
• Edema
• Hypertension
• Inflammation
• Vasospasm

ABDE

• A client has been admitted with a diagnosis of a possible C7 compression injury. A CT scan with contrast of the cervical spine is ordered. Which

action should the nurse perform?

• Remove all metal objects.
• Supply in-line mobilization of the neck.
• Ask if the client is allergic to seafood or radiopaque dye.
• Prep the client's neck with povidone-iodine solution.

C

• A client with an SCI has somatosensory-evoked potentials (SEPs) testing performed 2 days after admission to help establish a functional

prognosis. What conclusion would the nurse draw if the client had no SEPs during the test?

• The SCI is complete.
• The SCI is unstable.
• An upper motor neuron lesion is present.
• A lower motor neuron injury is present

A

• Which type of testing can determine the exact point on the client where normal sensation is present?
• Dermatomes

B. MRI

• Proprioception
• SEPs

A Absent reflexes, flaccidity, and loss of sensation below the level of injury are signs of which condition?

• Priapism

B.Autonomic dysreflexia

• Neurogenic shock
• Spinal shock

D

• Which SCI requires long-term mechanical ventilation?

A. C1-C2

B. C6-C7

C. T1-T5

• All clients with SCI require long-term mechanical ventilation.

A

The main cause of complications or death post-SCI is related to which condition?

• Sepsis
• Respiratory complications
• Autonomic dysreflexia
• Bradycardia

B

• A client is admitted to the unit with a C8 SCI. Which statement is true about recovery after this injury?
• The client will be able to eat independently.
• The client will be independent with dressing.
• The client will require an electric wheelchair.
• The client will require major assistance with bowel and bladder issues.
• The client will require major assistance for bathing.

A,B C8 injury -Nerves control some hand movement.

• Should be able to grasp and release objects
• Can do most activities of daily living by themselves, but may need assistance with more difficult tasks

-May also be able to drive an adapted vehicle -Little or no voluntary control of bowel or bladder, but may be able to manage on their own with special equipment

• Which sign indicates autonomic dysreflexia?

A. Heart rate: 60 beats per minute

B. Blood pressure: 220/120

• Priapism
• Poikilothermia

B

• The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After

stabilizing the client's cervical spine, which action should the nurse take next?

• Carefully remove the driver from the car.
• Assess the client's pupils for reaction.
• Assess the client's airway.
• Attempt to wake the client up by shaking him.

3

• The nurse should stabilize the client's neck prior to removal from the car.
• The nurse must stabilize the client's neck before doing any further assessment. Most nurses don't carry penlights, and the client's pupil

reaction can be determined after stabilization.

• The nurse must maintain a patent air- way. Airway is the first step in resuscitation.
• Shaking the patient could cause further damage, possibly leading to paralysis.

TEST-TAKING HINT: Remember that, in a question asking about which action should be taken first, all of the answers are interventions, but only one should be implemented first. There are very few "always" situations in the health-care profession, but in this situation, unless the client's car is on fire or under water, stabilizing the client's neck is always priority, followed by airway.

• In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock?
• No reflex activity below the waist.
• Inability to move upper extremities.
• Complaints of a pounding headache.
• Hypotension and bradycardia.

1

• Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist;

therefore, no reflex activity below the waist would be expected.

• Assessment of the movement of the upper extremities would be more appropriate with a higher level injury; an injury in the cervical area might

cause an inability to move the upper extremities.

• Complaints of a pounding headache are not typical of a T12 spinal injury.
• Hypotension (low blood pressure) and tachycardia (rapid heart rate) are signs of hypovolemic or septic shock, but these do not occur in

spinal shock.TEST-TAKING HINT: If the test taker does not have any idea what the answer is, an attempt to relate the anatomical position of keywords in the question stem to words in the answer options is appropri ate. In this case, T12, mentioned in the stem, is around the waist, so answer options involving the anatomy above that level (e.g., the upper extremities) can be eliminated.

• The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse

implement?

• Keep oxygen via nasal cannula on at all times.
• Administer low-dose subcutaneous anticoagulants.
• Perform active lower extremity ROM exercises.
• Refer to a speech therapist for ventilator-assisted speech.

2

• Oxygen is administered initially to maintain a high arterial partial

pressure of oxygen (PaO2) because hypoxemia can worsen a neurological deficit to the spinal cord initially, but this client is in the rehabilitation department and thus not in the initial stages of the injury.

• Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities

as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.

• The client is unable to move the lower extremities. The nurse should do passive ROM exercises.
• A client with a spinal injury at C4 or above would be dependent on a ventilator for breathing, but a client with an L1 SCI would not.

TEST-TAKING HINT: The test taker

should notice any adjectives such as "rehabilitation," which should clue the test taker into ruling out oxygen, which is for the acute phase. The test taker should also be very selective if choosing an answer with a definitive word such as "all" (option "1").