Spinal Cord Injury NCLEX

Spinal Cord Injury NCLEX

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Students also studied Terms in this set (26) University of North TexasHMGT 2460 Save Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview Spinal Cord Injury NCLEX Questions...53 terms Maria_Coronado22 Preview Spinal Cord Injury NCLEX Questions...11 terms kayc0622Preview Nclex Q 32 terms kar The nurse is caring for a patient admitted with a spinal cord injury following 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

Correct Answer(s): B

About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury?

• Bradycardia
• Hypertension
• Neurogenic spasticity
• Bounding pedal pulses

Correct Answer(s): A

Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the following assessment findings would alert the nurse to the presence of autonomic dysreflexia?

• Tachycardia
• Hypotension
• Hot, dry skin
• Throbbing headache

Correct Answer(s): D

Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority?

• Risk for impairment of tissue integrity caused by

paralysis

• Altered patterns of urinary elimination caused by

quadriplegia

• Altered family and individual coping caused by the

extent of trauma

• Ineffective airway clearance caused by high cervical

spinal cord injury

Correct Answer(s): D

Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority.Remember the ABCs.Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the nurse to the possibility of 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

Correct Answer(s): A

Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.Which of the following interventions should the nurse perform in the acute care of a patient with autonomic dysreflexia?

• Urinary catheterization
• Administration of benzodiazepines
• Suctioning of the patient's upper airway
• Placement of the patient in the Trendelenburg position

Correct Answer(s): A

Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated and suctioning is likely unnecessary.Nurse is assessing a patient who has a spinal cord injury?Which should the nurse include in the nervous system assessment to determine the extent of the patient's injury?select all that apply.

• vital sign
• romberg test
• plantar reflexes
• bilatereal hand grasps
• description of trauma

Correct Answer (s): a, c, d, e

the assessment to determine the level of spinal cord injury includes analyzing the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma.Romberg test must be performed while standing therefore not suitable for unstable patient A patient has impairments from a SCI at C4 classified as incomplete C on the American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient assessment is the nurse likely to observe in this patient?

• poor propricopetor in the legs
• poor peristalsis in the intestines
• Absent gag and blinking reflexes
• Absent bladder fulness sensation

Answer is B A patient who has a SCI has neurologic impairment to all extremities and the diaphragm. However, because the injury is C on the ASIA impairment Scale, sensory function can be intact but motor function will be impaired significantly or absent.the patient can lose moderate to complete peristatlic action in the intestines but should reatine the ability to sense bladder fulnessand the position of the legs.

The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion to a male patient who has fractures of the cervical vertebrae. Which intervention would prevent or detect adverse effects of the medication?

• record pt baseline weight
• adminster PPI( proton pump inhibitor)
• Check the hear rate for bradycardia
• suction the patient's oropharynx

Correct Answer(s): B

the nurse should adminster PPI because they are at high risk for Gi erosion and bleeding. from the steroid.A male patient has a pinal cord injury at L 1-2 . Which clinical manifestation of the patient's injury is the nurse likely to observe before spinal shock resolves?

• opoiod analgesic Iv for foot pain
• able to blance in sitting position
• unresponsive quadriceps muscle
• requites asssist control ventilation

Correct Answer(s) : C

during spinal shock neuromuscular function is lost below the level of the injury along with hyporeflexia and loss of sensation. So the pt will not be able to sit until the pinal shock resolves.A female nurse is injured in an automobile accident and suffers acute compresssion of the anterior apinal cord at T8-10 Which nursing rols is a potential source of employment for the patients after completing rehabilitation ?

• Certified nurse practioner
• Community health nursing
• Hospital case mangement
• Inpatient behavioral health

Correct C. Hospital case management(s) the nurse in most likely to have an anterior cord syndrome resulting in the loss of neuromuscular and pain and temp sensation below t8. Pt will have full use of upper extremities , upper back, and resp muscles.thus she will be in a wheel chair.A 25-yr old male pt who is a professional motorcross racer has anterior spinal cord syndrome at T10. His history includes tobacco use, alcohol abuse, marijuana abuse.What is the nurse's priority during rehabilation?

• Monitor the patient 4 times an hour
• Encourage him to verbalize feeling.
• Prevent urniary tract infection
• Teach about using gastrocolic reflex

Correct answer(s) B The pt is at high risk for depression and self-injury because he is likely to lose function below the umblicus . resulting in loss motor function. In addition he will need to be in a wheelchair, impaired sexual function, and can not use tobacco, alcohol, marijuana abuse for coping.A 70 yr old patient who has a spinal cord injury at C8 resulting in central cord syndrome. Which effect of the patient's most likely to be life threatening after completeing rehabiliation?

• increased bone density loss
• higher tisk for tissue hpoxia
• vasomotor compensation lost
• Weakness of thoracic muscles

Correct Answer(s): D

Weakness of thoracic muscle is most likely to cause life-threatening complications because affects patients oxygentation and ventilation.

A patient with a neck fracture at the C5 level is admitted to the intensive care unit (ICU) following initial treatment in the emergency room. During initial assessment of the patient, the nurse recognizes the presence of spinal shock on finding

• hypotension, bradycardia, and warm extremities.
• involuntary, spastic movements of the arms and legs.
• the presence of hyperactive reflex activity below the

level of the injury.

• flaccid paralysis and lack of sensation below the level

of the injury.

Correct Answer(s): D

Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss of sensation, and flaccid paralysis below the area of injury. Hypotension, bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary spastic movements and hyperactive reflexes are not seen in the patient at this stage of spinal cord injury.When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by the nurse should be to

• administer oxygen at 7 to 9 L/min with a face mask.
• place the hands on the epigastric area and push

upward when the patient coughs.

• encourage the patient to use an incentive spirometer

every 2 hours during the day.

• suction the patient's oral and pharyngeal airway.

Correct Answer(s): B

Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not help expel respiratory secretions. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The nurse will teach the patient and family that

• use of the shoulders will be preserved.
• full function of the patient's arms will be retained.
• total loss of respiratory function may occur temporarily.
• elevations in heart rate are common with this type of

injury.

Correct Answer(s): B

Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with injuries above the T6 level.The health care provider orders administration of IV methylprednisolone (Solu-Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at the T10 level 3 hours ago. When evaluating the effectiveness of the medication the nurse will assess

• blood pressure and heart rate.
• respiratory effort and O2 saturation.
• motor and sensory function of the legs.
• bowel sounds and abdominal distension.

Correct Answer(s): C

Rationale: The purpose of methylprednisolone administration is to help preserve

neurologic function; therefore, the nurse will assess this patient for lower- extremity function. Sympathetic nervous system dysfunction occurs with injuries at or above T6, so monitoring of BP and heart rate will not be useful in determining the effectiveness of the medication. Respiratory and GI function will not be impaired by a T10 injury, so assessments of these systems will not provide information about whether the medication is effective.A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate?

• Teaching the patient how to self-catheterize
• Assisting the patient to the toilet q2-3hr
• Use of the Credé method to empty the bladder
• Catheterization for residual urine after voiding

Correct Answer(s): A

Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.