SPINAL CORD INJURY PART 1

Pearson Spinal Cord Injury Leave the first rating Students also studied Terms in this set (26) Science MedicineNursing Save Spinal Cord Injury (Pearson) 11 terms holly_brock5Preview

SPINAL CORD INJURY (PART 1)

45 terms luis_ezquerraPreview Spinal Cord Injury NCLEX 26 terms ET0003Preview Emerge 26 terms mlm The nurse is teaching at a community camp about the risk factors for spinal cord injury (SCI).Which group should the nurse indicate as having the highest risk?

• Single, young adult men
• Children
• Older adult women
• Adolescents

A Which assessment is helpful when assessing for autonomic dysreflexia?

• Blood pressure
• Hemoglobin
• Arterial blood gas
• American Spinal Injury Association (ASIA) score

A The nurse is teaching a community group about how to prevent compression-type spinal cord injuries (SCIs).Which precaution should the nurse include?

• Always checking water level before diving
• Restricting driving when taking medications that affect

mentation

• Avoiding sliding headfirst into base while playing

baseball

• Removing any scatter rugs from home

A

The nurse is performing an assessment using the American Spinal Injury Association (ASIA) Impairment Scale. The nurse notes that the patient has no movement or sensory function below the level of the hips.Which classification should the nurse determine as correct for this patient?

• Complete
• Motor incomplete
• Sensory incomplete
• Normal

A A patient is admitted with an injury in the cervical region of the spinal cord. The nurse monitors the patient's respiratory function.Which reason explains the nurse's action?

• Bone fragments from the damaged vertebrae can

lodge in the trachea and bronchi.

• The patient is at high risk of aspiration caused by

pressure on the esophagus from the injury.

• Hemorrhage in the spinal cord will interfere with nerve

transmission to the lungs.

• The muscles required for breathing might not function.

D A patient with partial paraplegia is at 36 weeks of her pregnancy. She asks the nurse, "How will I know if I am in labor when I have no feeling below my waist?" Which response by the nurse is correct?

• "Because the uterus is not controlled by spinal nerves,

you will feel the labor pains."

• "You will have to have a scheduled cesarean birth since

your uterus cannot contract."

• "You will need to monitor your body for changes other

than labor pains, such as abdominal muscle tightening."

• "You will only know you are in labor if your water

breaks." C Which intervention is the priority for a patient immediately after a suspected spinal cord injury?

• Conducting a focused neurologic assessment
• Monitoring blood pressure
• Assessing the airway
• Immobilizing the neck and spine

C

The nurse prepares a patient with a spinal cord injury for insertion of a nasogastric tube. The patient wants to know the purpose of this placement.Which statement by the nurse is accurate?

• "We need to prevent bowel movements since you have

no control in that area."

• "We will use this to aspirate stomach contents to

monitor for hemorrhage."

• "Insertion of this type of tube has been shown to

increase motility in the stomach and small intestine."

• "This tube will allow us to provide nourishment and

medications without the risk of aspiration." D The nurse receives an order to place a nasogastric tube in a patient with a spinal cord injury and a suspected ileus.The patient asks the nurse why the procedure is being performed.Which statement should the nurse include in the explanation?

• "We need to prevent bowel movements since you have

no control in that area."

• "This tube will be used to provide nourishment."
• "Insertion of this type of tube will increase motility in

the stomach and small intestine."

• "Your bowels are sluggish, and this tube will empty

your stomach and prevent nausea." D The nurse is discussing prognosis with a patient who experienced a gunshot injury and now has Brown- Sequard syndrome. Which information should the nurse communicate to the patient regarding recovery?

• Recovery usually starts in the lower extremities and

moves upward.

• Brown-Sequard has the best prognosis among all

types of incomplete spinal cord injury syndromes.

• Prognosis for recovery of bowel and bladder function

is poor.

• Only 10-20% of patients experience motor recovery.

B A patient sustained fractures at C5 and C6. The healthcare provider states, "We need to do something about the spinal swelling." Which type of medication should the nurse anticipate the healthcare provider will order?

• Antiemetic
• Corticosteroid
• Antispasmodic
• Vasopressor

B

A patient is being discharged for a spinal cord injury (SCI) that resulted in partial paralysis in both legs. The patient is able to perform most self-care activities, including getting to and from the wheelchair with assistance.Which patient statement should make the nurse recognize the need for a home health referral when preparing for discharge?

• "My spouse can leave things on the counter for me to

reach."

• "My wheelchair will fit through the bathroom door but

not the laundry room door."

• "I am glad that my bedroom is on the main floor of our

house."

• "I can wait until my spouse is home from work to help

me go to the bathroom." D The nurse on the inpatient rehabilitation unit is preparing a 15-year-old patient with cervical spinal cord injury for discharge to home.Which intervention should the nurse provide to facilitate the discharge?

• Discussing the patient's prognosis and expected

lifespan with the parents

• Providing information about group home options
• Discussing ways to make the home environment

accessible

• Providing information about home schooling

C The medical record of a patient who sustained a spinal cord injury indicates that the patient experienced a whiplash injury.Which type of excessive force does the nurse suspect to have been placed on the vertebral column?

• Transection of the spinal cord
• Compression
• Hyperextension
• Hyperflexion

C Which strategy would be most helpful in preventing the most common cause of spinal cord injuries (SCIs) in older adult patients?

• Teaching the patient about keeping the environment

free of clutter

• Teaching the patient about using the shoulder strap of

the seat belt

• Reminding the patient not to drive when taking

medications that affect mentation

• Suggesting the use of a home emergency call system

A