Spinal injury and ICP Nclex Questions

Spinal injury and ICP Nclex Questions Leave the first rating Students also studied Terms in this set (20) Science MedicineNursing Save Spinal Cord Injury NCLEX Questions...53 terms Maria_Coronado22 Preview Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview Spinal Cord Injury NCLEX 26 terms ET0003Preview Spinal C 11 terms hol 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.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 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.

Urinary function during the acute phase of spinal cord injury is maintained with

• an indwelling catheter
• intermittent catheterization
• insertion of a suprapubic catheter
• use of incontinent pads to protect the skin
• an indwelling catheterization

The healthcare provider has ordered IV dopamine (Intropin) for a patient in the emergency deparement with a spinal cord injury. The nurse determines that the drug is having the desired effect when assessment findings include

• pulse rate of 68
• respiratory rate of 24
• BP of 106/82
• temperature of 96.8
• BP of 106/82

Rationale: Dopamine is a vasopressor that is used to maintain BP during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is not treated with medications.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 initial action of the nurse is to

• call the physician
• check the patient's temperature
• take the patient's BP
• elevate the HOB to 90 degrees
• Take the patient's BP

One indication for surgical therapy of the patient with a spinal cord injury is when

• there is incomplete cord lesion involvement
• the ligaments that support the spine are torn
• a high cervical injury causes loss of respiratory function
• evidence of continued compression of the cord is

apparent

• evidence of continued compression of the cord is apparent

Rationale: Although surgical treatment of spinal cord injuries often depends on

the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client?

• condom catheter
• intermittent urinary catheterization
• crede's method
• indwelling urinary catheter
• condom catheter

Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a condom catheter is an appropriate method and is noninvasive.B & C are for flaccid bladder.A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. which of the following types of prescribed medications should the nurse clarify with the provider?

• glucocorticoids
• plasma expanders
• H2 antagonists
• muscle relaxants
• muscle relaxants

Rationale: The client will still be in spinal shock 24 hours following the injury. the client will not experience muscle spasms until after the spinal shock has resolved, making muscle relaxants unnecessary at this time.