SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST

SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST

VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS

AND CORRECT ANSWERS WITH

RATIONALES|AGRADE

. 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 - ANSWER- c. Flexion-rotation

• 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 - ANSWER- a. L1-2

• A patient with a T4 spinal cord injury experiences neurogenic shock as a result

of sympathetic nervous system dysfunction. What would the nurse recognize as characteristic of this condition?

• Tachycardia
• Hypotension
• Increased cardiac output
• Peripheral vasoconstriction - ANSWER- b. Hypotension

• A patient with a C7 spinal cord injury 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. 1 / 4

• elevate the head of the bed to 90 degrees. - ANSWER- c. take the patient's blood

pressure.

• For a 65-year-old woman who has lived with a T1 spinal cord injury for 20

years, which health teaching instructions should the nurse emphasize?

• A mammogram is needed every year.
• Bladder function tends to improve with age.
• Heart disease is not common in people with spinal cord injury.
• As a person ages, the need to change body position is less important. -

ANSWER- a. A mammogram is needed every year.

• The most common early symptom of a spinal cord tumor is
• urinary incontinence.
• back pain that worsens with activity.
• paralysis below the level of involvement.
• impaired sensation of pain, temperature, and light touch. - ANSWER- b. back

pain that worsens with activity.

• During assessment of the patient with trigeminal neuralgia, the nurse should

(select all that apply)

• inspect all aspects of the mouth and teeth.
• assess the gag reflex and respiratory rate and depth.
• lightly palpate the affected side of the face for edema.
• test for temperature and sensation perception on the face.
• ask the patient to describe factors that initiate an episode. - ANSWER- a. inspect

all aspects of the mouth and teeth.

• test for temperature and sensation perception on the face.
• ask the patient to describe factors that initiate an episode.

• During routine assessment of a patient with Guillain-Barré syndrome, the nurse

finds the patient is short of breath. The patient's respiratory distress is caused by

• elevated protein in the CSF.
• immobility resulting from ascending paralysis.
• degeneration of motor neurons in the brainstem and spinal cord.
• paralysis ascending to the nerves that stimulate the thoracic area - ANSWER- d.

paralysis ascending to the nerves that stimulate the thoracic area

• A nurse is caring for a patient newly diagnosed with chronic inflammatory

demyelinating polyneuropathy (CIDP). Which statement can the nurse accurately use to teach the patient about CIDP? 2 / 4

• "Corticosteroids have little effect on this disease."
• "Maintenance therapy will be needed to prevent relapse."
• "You will go into remission in approximately eight weeks."
• "You should be able to walk without help within three months." - ANSWER- b.

"Maintenance therapy will be needed to prevent relapse."

• A patient has a spinal cord injury at T4. Vital signs include falling blood

pressure with bradycardia. The nurse recognizes that the patient is experiencing

• a relative hypervolemia.
• an absolute hypovolemia.
• neurogenic shock from low blood flow.
• neurogenic shock from massive vasodilation. - ANSWER- d. neurogenic shock

from massive vasodilation.

A patient has been admitted to the hospital with a T3-level complete spinal cord injury. The nurse has to plan the home-based rehabilitation for this patient. When creating the care plan, the nurse considers the activities that the patient is able to do independently. What activities should the nurse consider to make maximum use of patient's abilities? Select all that apply.

• Independent self-care is possible.
• Independent wheelchair mobility is possible.
• Patient may be able to drive with hand controls.
• Patient will be able to climb stairs independently.
• Patient will be able to have effective coughing ability. - ANSWER- a, b, c

Rationale The patient with a T3-level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve.Therefore, the patient may have the following potentials: full independence in self- care and in a wheelchair, ability to drive a car with hand controls, independent standing in a standing frame. Abdominal muscles are affected, so the ability to cough is lost. The patient may also not be able to climb stars due to the injury.

A patient has been admitted to the hospital with a spinal cord injury. Following the assessment, the health care provider concludes that the injury is above T12. What signs and symptoms related to the gastrointestinal system would indicate an injury above T12? Select all that apply.

• The patient has an absence of bowel sounds. 3 / 4

• There is excess gastric distention, and the stomach is hard.
• The patient is constipated and is passing hard stools with straining.
• The sensation of a full bowel is perceived by the patient, and fecal incontinence

is present.

• The sensation of a full bowel is not perceived by the patient, and fecal

incontinence is present. - ANSWER- B, D Rationale An injury above T12 leads to development of a reflexic bowel, wherein nervous interactions between the colon (large intestine) and the brain are interrupted. As a result, the person may not feel the need to have a bowel movement. However, stool is still building up in the rectum. The build-up triggers a reflex, causing the rectum and colon to react, leading to a bowel movement without warning. When the sensation of a full bowel is perceived by the patient and the patient has fecal incontinence, it is a lower-level spinal cord injury (below T12). In spinal cord injury, it is usually incontinence that occurs. When the injury is above T5, paralytic ileus may be present and bowel sounds may be absent.

A nurse is assessing a patient with a T2-level spinal cord injury. The nurse notices that there is a kink in the catheter, the bladder is distended, and the blood pressure is 220/100 mm Hg. What nursing interventions would be appropriate for this patient if the nurse suspects autonomic dysreflexia? Select all that apply.

• Lower the head of the bed.
• Monitor blood pressure regularly.
• Make the patient lie flat on the bed.
• Notify the primary health care provider.
• Check for the presence of bowel impaction.
• Remove the kink in the catheter and drain the bladder. - ANSWER- B. Monitor

blood pressure regularly.

• Notify the primary health care provider.
• Check for the presence of bowel impaction.
• Remove the kink in the catheter and drain the bladder.

Rationale A sudden rise in blood pressure for a spinal cord injury patient above the level of T6 is generally indicative of autonomic dysreflexia. Nursing interventions in a serious emergency like autonomic dysreflexia include notifying the primary health care provider and determining the cause. The blood pressure should be regularly monitored; administration of an alpha-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the

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