Spinal Cord Injury Practice Questions

Spinal Cord Injury Practice Questions Leave the first rating Students also studied Terms in this set (12) Science MedicineNursing Save Spinal Cord Injury NCLEX 26 terms ET0003Preview

Exam 1: Spinal Cord Injury Questions...

30 terms danielle_white47 Preview Head Injury Practice Questions 37 terms LeMoyneFreeman Preview Nclex Q 32 terms kar The nurse arrives at the site of a motor vehicle accident and stops to help. The driver is unconscious. After stabilizing the client's cervical spine, which action should be taken 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
• Assess the client's airway

Airway is first step in resuscitation In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock?

• No reflex activity below the waist
• Inability to move upper extremities
• Complaints of a pounding headache
• Hypertension and tachycardia
• No reflex activity below the waist

Neurogenic 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 should be expected

The rehabilitation nurse caring for the client with a Lumbar 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

• Administer low-dose subcutaneous anticoagulants

DVT is a potential complication of immobility, and this patient cannot move their lower extremities.The nurse in the neurointensive care unit is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply.

• Monitor the pulse oximetry reading.
• Provide pureed foods six (6) times a day.
• Encourage coughing and deep breathing.
• Assess for autonomic dysreflexia.
• Administer intravenous corticosteroids.

1, 3, 5

Oxygen prevents hypoxemia, breathing exercises strengthen the lungs, and corticosteroids decrease inflammation and prevent edema around the spinal cord causing breathing issues The home health nurse is caring for a 28 yo client with a T10 SCI who says, "I can't do anything. Why am I so worthless? Which statement by the nurse would be most therapeutic

• This must be very hard for you. You're feeling

worthless?

• You shouldn't feel worthless, you are still alive
• Why do you feel worthless? You can still use your arms
• If you attend a work rehab program you wouldn't feel

worthless

• This must be very hard for you. You're feeling worthless?

The client is diagnosed with an SCI and is scheduled for an MRI. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test?

• Do you have trouble hearing
• Are you allergic to any dairy
• Have you eaten anything in the last 8 hours
• Are you uncomfortable in closed spaces
• Are you uncomfortable in closed spaces

People with claustrophobia can be medicated

The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110.Which intervention should the emergency department nurse implement?

• Keep the client flat in bed.
• Dim the lights in the room.
• Assess for bladder distention.
• Administer a narcotic analgesic.
• Assess for bladder distention.

This is an acute emergency caused by exaggerated autonomic responses to stimuli and occurs after spinal shock has resolved in the client with an SCI above T6. The most common cause is full bladder The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client?

• Discuss how to correctly remove the insertion pins.
• Instruct the client to report reddened or irritated skin

areas.

• Inform the client that the vest liner cannot be changed.
• Encourage the client to remain in the recliner as much

as possible.

• Instruct the client to report reddened or irritated skin areas.

Avoid pressure ulcers The ICU nurse is caring for a client with a T1 SCI. When the nurse elevates the HOB to 30 degrees, the client complains of light-headedness and dizziness. The client's vital signs are T 99.2 F, P 98, R 24, and BP 84/40. Which action should the nurse implement?

• Notify the provider ASAP
• Calm the client down by talking therapeutically
• Increase the IV rate by 50 mL/hour
• Lower the HOB immediately
• Lower the HOB immediately

For the first two weeks after an SCI above T7, the blood pressure tends to be unstable and low. Slight elevations of the HOB can cause profound hypotension The nurse is caring for clients on the rehabilitation unit.Which clients should the nurse assess first after receiving report?

• The client with a C6 SCI who is complaining of dyspnea

and has crackles

• The client with an L4 SCI who is crying and very upset

about being discharged home

• The client with an L2 SCI who is complaining of a

headache and feeling very hot

• The client with a T4 SCI who is unable to move the

lower extremities

• The client with a C6 SCI who is complaining of dyspnea and has crackles

This client has S & S of respiratory complication

Which nursing task would be most appropriate to delegate to the UAP?

• Teach Crede's maneuver to the client needing to void
• Administer the tube feeding to the client who is

quadriplegic

• Assist with bowel training by placing the client on the

bedside commode

• Observe the client demonstrating a self-catheterization

technique

• Assist with bowel training by placing the client on the bedside commode

The 34 yo male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement?

• Refer the client to the American Spinal Cord Injury

Association

• Refer the client to the state rehabilitation commission
• Ask the social worker about applying for disability
• Suggest the client talk with his significant other about

this concern

• Refer the client to the state rehabilitation commission

They will help evaluate and determine if the client can receive training or education for another occupation after injury