Spinal injury and ICP Nclex Questions

Spinal injury and ICP Nclex Questions Leave the first rating Students also studied Terms in this set (61) Save med surg 2 exam 2 136 terms Ashleymh1234 Preview Pancreatitis NCLEX (ATI, Evolve, Lew...13 terms Jennster17Preview Burns 31 terms LucyCooper3Preview Ch 14 P 70 terms yew A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?

• Try to calm the patient and make the environment

soothing.

• Assess for a full bladder.
• Notify the healthcare provider.
• Prepare the patient for diagnostic radiography.

Correct Answer: 2

Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel.Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore." Which is the most appropriate action by the nurse?

• Remind the patient of her injury and try to comfort her.
• Call the healthcare provider and get an order for

radiologic evaluation.

• Prepare the patient for surgery, as her condition is

worsening.

• Explain to the patient that this could be a common,

temporary problem.

Correct Answer: 4

Rationale: Spinal shock is a condition almost half the people with acute spinal

injury experience. It is characterized by a temporary loss of reflex function below level of injury, and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level. In this case, the nurse should explain to the patient what is happening.The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner- Wells tongs?

• "I will have less pain if I use the halo device."
• "The halo device will allow me to get out of bed."
• "I am less likely to get an infection with the halo

device."

• "The halo device does not have to stay in place as

long."

Correct Answer: 2

Rationale: A halo device will allow the patient to be mobile since it does not

require weights like the Gardner-Wells tongs. The patient's pain level is not dependant on the type of stabilization device used. The patient does not have a great risk of infection with the Garnder-Wells tongs; both devices require pins to be inserted into the skull. The time required for stabilization is not dependant on the type of stabilization device used.

The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some nursing actions are contraindicated with IICP. Which nursing action should be avoided?

• Reposition the patient every two hours.
• Position the patient with the head elevated 30 degrees.
• Suction the airway every two hours per standing

orders.

• Provide continuous oxygen as ordered.

Correct Answer: 3

Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to maintain a patent airway but not as a matter of routine.Maintaining patient comfort by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?Select all that apply.

• modifying the traction weights as needed
• assessing the patient's skin integrity
• applying the traction upon admission
• administering pain medication
• providing passive range of motion

Correct Answer: 2,4,5

Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.A patient has manifestations of autonomic dysreflexia.Which of these assessments would indicate a possible cause for this condition?Select all that apply.

• hypertension
• kinked catheter tubing
• respiratory wheezes and stridor
• diarrhea
• fecal impaction

Correct Answer: 2,5

Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing

allowing the bladder to become full, triggering massive vasoconstriction below the injury site, producing the manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained elevated blood pressure, may indicate fecal impaction. The other answers will not cause autonomic dysreflexia.An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed?Select all that apply.

• Immobilize the neck using rolled towels or a cervical

collar.

• The patient will be placed in a supine position
• The patient will be placed on a ventilator.
• The head of the bed will be elevated.
• The patient's head will be secured with a belt or tape

secured to the stretcher.

Correct Answer: 1,2,5

Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

• autonomic dysreflexia
• autonomic crisis
• autonomic shutdown
• autonomic failure

Correct Answer: 1

Rationale: Be attuned to the prevention of a distended bladder when caring for

spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

Which patient is at highest risk for a spinal cord injury?

• 18-year-old male with a prior arrest for driving while

intoxicated (DWI)

• 20-year-old female with a history of substance abuse
• 50-year-old female with osteoporosis
• 35-year-old male who coaches a soccer team

Correct Answer: 1

Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less risk-taking behavior than young men.The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?

• "Tissue repair does not begin for 72 hours."
• "The edema extends the level of injury for two cord

segments above and below the affected level."

• "Neurons need time to regenerate so stating the injury

early is not predictive of how the patient progresses."

• "Necrosis of gray and white matter does not occur until

days after the injury."

Correct Answer: 2

Rationale: Within 24 hours necrosis of both gray and white matter begins if

ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury.A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?

• hemiplegia
• paresthesia
• paraplegia
• quadriplegia

Correct Answer: 4

Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy?

• Provide the patient with an air mattress.
• Place pillows under patient to help patient turn.
• Teach the patient to grasp the side rail to turn.
• Use the log roll to turn the patient to the side.

Correct Answer: 4

Rationale: A patient who has undergone a laminectomy needs to be turned by log

rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission,

the findings are: blood pressure 90/60 (as compared to

136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are consistent with which of the following?

• paralysis
• spinal shock
• high cervical injury
• temporary hypovolemia

Correct Answer: 2

Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs and symptoms mentioned, the additional sign of absence of the cremasteric reflex is associated with spinal shock. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in an spinal injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three minutes while searching for the cause in order to prevent loss of consciousness or death.By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is which of the following?

• hypoxia
• bradycardia
• elevated blood pressure
• tachycardia

Correct Answer: 3

Rationale: Autonomic dysreflexia is an emergency that requires immediate

assessment and intervention to prevent complications of extremely high blood pressure. Additional nursing assistance will be needed and a colleague needs to reach the physician stat.A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by

• increased vasomotor tone after injury
• a temporary loss of sensation and flaccid paralysis

below the level of injury

• loss of parasympathetic nervous system innervation

resulting in vasoconstriction

• loss of sympathetic nervous system innervation

resulting in peripheral vasodilation

• loss of sympathetic nervous system innervation resulting in peripheral

vasodilation A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min.Which of the following acctions should the nurse take first?

• notify the provider
• sit the client upright in bed
• check the client's urinary catheter for blockage
• administer antihypertensive medication
• sit the client upright in bed

Rationale: The greatest risk to the client is experiencing a cerebrovascular

accident (stroke) secondary to elevated BP. The first action by the nurse is elevate the head of the bed until the client is in an upright position. this will lower the BP secondary to postural hypotension.Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, the nurse anticipates that the patient will need

• IV fluids
• tube feedings
• parenteral nutrition
• nasogastric suctioning
• nasogastric suctioning

Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and NG suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who had difficulty swallowing and not until peristalsis is returned; PN would be used only if the paralytic ileus was unusally prolonged.An initial incomplete spinal cord injury often results in complete cord damage because of

• edematous compression of the cord above the level of

the injury

• continued trauma to the cord resulting from damage to

stabilizing ligaments

• infarction and necrosis of the cord caused by edema,

hemorrhage, and metabolites

• mecheanical transection of the cord by sharp vertebral

bone fragments after the initial injury

• c. infarction and necrosis of the cord caused by edema, hemorrhage, and

metabolites Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may increase the damage as it extends above and below the injury site.