EAQ Spinal Cord Problems

The nurse is performing an assessment on a patient 6 hours after diskectomy notices the presence of clear drainage from the incision site. For which finding would the nurse evaluate the patient? Sudden headache Nausea and vomiting Decerebrate positioning Change in level of consciousness

Sudden headache

Which device would the nurse recommend to help prevent pressure injury in the patient with a spinal cord injury? Trapeze Chair pad Hot water bottle Thromboembolism-deterrent (TED) hose

Chair Pad

The nurse is performing a postoperative assessment on a patient after an open back diskectomy. Which color of wound drainage would cause the nurse to suspect a cerebrospinal fluid leak? Clear Green Yellow Red

Clear

The nurse is teaching a patient with a spinal cord injury about self-care in the halo device. Which instruction would the nurse plan to include? "You can begin driving 1 week after discharge." "Keep straws available for drinking fluids." "Swimming is recommended to keep active." "Avoid using a pillow under your head while sleeping."

"Keep straws available for drinking fluids."

A patient is unable to move and has no tactile sensation below the level of spinal injury after a diving accident. The health care provider is unable to elicit reflexes. The patient's family member asks whether the patient will be paralyzed. Which response would the nurse provide to the family member? "Based on these findings, permanent paralysis is likely." "Patients with these symptoms usually die from these injuries." "These findings may indicate a temporary response to the injury." "If these symptoms persist longer than 48 hours, paralysis will occur."

"These findings may indicate a temporary response to the injury."

Which statement about autonomic dysreflexia (AD) is accurate? AD occurs when a spinal cord injury is present below T6. AD can be caused by a distended bladder. AD causes orthostatic hypotension in the patient. AD increases the patient's heart rate.

AD can be caused by a distended bladder.

Which initial assessment is the priority for a patient with a spinal cord injury? Level of consciousness Degree of injury scale Airway, breathing, and circulation Ability to recall the events of the injury

Airway, Breathing, and Circulation

Young Males Rationale

Almost 80% of SCIs occur in young males, and the majority of them are Euro-Americans.

A patient returns to the surgical unit after undergoing an anterior cervical diskectomy and fusion. Assist with ambulation Administer pain medication Assess airway and breathing Check the patient's ability to void

Assess airway and breathing

A patient with severe muscle spasticity has been prescribed tizanidine. Which possible adverse effect of tizanidine would the nurse explain to the patient? Hirsutism Drowsiness Hypertension Tachycardia

Drowsiness

A patient with a spinal cord injury is on medication to control severe muscle spasticity. After a few days of receiving the medication, the patient experiences sedation, fatigue, dizziness, and changes in mental status. Which medication would the nurse suspect has contributed to these symptoms? Lamotrigine Lavetiracetam Gabapentin Intrathecal baclofen (ITB)

Intrathecal baclofen (ITB)

Which secondary spinal cord injury typically results from reduced or absent blood flow? Ischemia Hemorrhage Local edema Hypovolemia

Ischemia

Which situation may cause a patient with a primary spinal cord injury (SCI) to experience a secondary SCI? Ischemia Hemorrhage Local edema Hypovolemia Immobility

Ischemia Hemorrhage Local edema Hypovolemia

A patient is admitted to the health care unit with acute spinal injuries. Which initial assessment would the nurse perform? Blood glucose level Level of consciousness Volume of urine output Sensory and motor function Airway, breathing, and circulation

Level of Consciousness Sensory and Motor Function Airway, Breathing, and Circulation

Which secondary spinal cord injury results from increased interstitial fluid? Ischemia Hemorrhage Local edema Hypovolemia

Local Edema

A patient who has just undergone spinal surgery must be repositioned. Which action would the nurse take to move this patient? Log rolling the patient to the side Getting the patient up in a chair Placing the patient in the Trendelenburg position Lifting the patient in unison with other health care personnel

Log rolling the patient to the side

Which term is used for weakness in a patient's legs after a spinal cord injury (SCI)? Paraparesis Hypoesthesia Hyperesthesia Quadriparesis

Paraparesis

Ziconotide Rationale

Ziconotide therapy can cause psychotic symptoms like hallucinations and delusions. In such a case, the drug should be stopped immediately, and the adverse effects should be reported to the health care provider. Ziconotide can be taken with opioid analgesics. The nurse should assess the neurologic status of a patient with surgically implanted pumps below, not above the level of insertion. Ziconotide therapy does not cause blood glucose fluctuations.

A patient has received preoperative teaching about a microdiskectomy. Which statement by the patient indicates a correct understanding of the nurse's instruction? "I can go home the day of the procedure." "I can go home 48 hours after the procedure." "I'll have a drain in place after the procedure." "I'll need to wear special stockings after the procedure."

"I can go home the day of the procedure."

The nurse is teaching a patient and her husband about sexual function after a spinal cord injury. Which comment by the patient indicates a correct understanding of the understanding? "My children will be paralyzed." "I can no longer become pregnant." "I may still be able to get pregnant." "If I become pregnant, I cannot give birth."

"I may still be able to get pregnant."

Which patient statement indicates that teaching about self-care for a halo fixation device has been effective? "I will sleep without a pillow." "I will not drive until the device is removed." "I will restrict my fluid intake to 1 L per day." "I will apply corn starch under the vest every day."

"I will not drive until the device is removed."

Cervical Rationale

A patient with a cervical SCI is at high risk for respiratory compromise because the cervical spinal nerves (C3-5) innervate the phrenic nerve controlling the diaphragm.

Respiratory Therapist Rationale

A patient with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis.

ACDF Rationale

Assessment in the immediate postoperative period after an ACDF is maintaining an airway and ensuring that the patient has no problem with breathing.

Autonomic Dysreflexia Rationale

Autonomic dysreflexia refers to an excessive, uncontrolled sympathetic output that caused by a noxious stimulus. This stimulus often arises from a distended bladder.

A patient is admitted with excessive rotation of the cervical vertebra. Which assessment finding should the nurse consider as contributing to secondary injury in this patient? Temperature 98.2 Heart rate 94 beats/min and regular Blood pressure 78/56 mm Hg Respiratory rate 10 breaths/min and shallow Pulse oximeter 88% on room air

Blood pressure 78/56 mm Hg Respiratory rate 10 breaths/min and shallow Pulse oximeter 88% on room air

The nurse observes that the patient is unable to grasp a pen or form a fist when assessing motor function. Based on this assessment, what is the most likely level of spinal cord injury in the patient? C7 C8 C4 C5

C8

Which collaborative problem would the nurse prioritize for patients with acute spinal cord injuries (SCIs)? Complications caused by prolonged immobility or decreased mobility Cardiovascular instability-related hemorrhage or interruption of sympathetic innervation Decreased mobility and sensation related to spinal cord damage and edema Respiratory distress/failure related to aspiration or decreased diaphragmatic innervation Secondary SCI related to hypoperfusion, edema, or delayed spinal column stabilization

Cardiovascular instability-related hemorrhage or interruption of sympathetic innervation Decreased mobility and sensation related to spinal cord damage and edema Respiratory distress/failure related to aspiration or decreased diaphragmatic innervation Secondary SCI related to hypoperfusion, edema, or delayed spinal column stabilization

The nurse is caring for a patient after a motor vehicle crash. Which location of spinal cord injury (SCI) indicates that the patient is at high risk for respiratory complications? Sacral Lumbar Cervical Thoracic

Cervical

A patient is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to adjust to the home setting after the injury. Which resource would the nurse recommend? Internet searches Hospital library Health care provider's office staff Consumer organization support group

Consumer Organization Support Group

A patient with severe chronic back pain is receiving an intrathecal infusion ziconotide with a surgically implanted pump. Which action would the nurse take? Ensure that the patient does not receive any opioid medications during the infusion. Monitor the patient's blood glucose level regularly. Discontinue the infusion if the patient exhibits delusions. Assess the patient's neurologic status above the level of the pump's infusion.

Discontinue the infusion if the patient exhibits delusions.

Which complication commonly occurs after conventional diskectomy, laminectomy, or spinal fusion? Paralysis Dural tears Nerve injury Encephalitis Diskitis Bowel perforation

Dural Tears Nerve Injury Diskitis

The nurse is preparing to perform an intermittent urinary catheterization on a patient with a spinal cord injury. The patient reports a sudden onset of headache along with nausea and sweating, and the nurse assesses a blood pressure of 185/110 mm Hg. Which action would the nurse take first? Notify the Rapid Response Team. Elevate the head of the bed to an upright position. Perform the procedure to relieve the bladder distention. Reduce the temperature of the room to reduce the sweating.

Elevate the head of the bed to an upright position.

Which mechanism of spinal cord injury occurs when the head turns beyond the normal range? Hyperflexion Hyperextension Excessive rotation Vertical compression

Excessive Rotation

Which assessment finding indicates that a patient with a T4 spinal cord injury is developing autonomic dysreflexia? Sneezing Flushing of the neck Profuse facial diaphoresis Heart rate 52 beats/min and irregular Blood pressure 150/90 mm Hg

Flushing of the neck Profuse facial diaphoresis Heart rate 52 beats/min and irregular Blood pressure 150/90 mm Hg

Which finding would alert the nurse that a patient with a spinal cord injury is experiencing autonomic dysreflexia? Headache Bradycardia Hypertension Nasal stuffiness Cold, clammy skin

Headache Bradycardia Hypertension Nasal stuffiness

Which term is used for a patient's report of increased sensory sensation after a spinal cord injury (SCI)? Paraparesis Hypoesthesia Hyperesthesia Quadriparesis

Hyperesthesia

Which mechanism of spinal injury occurs when the head is suddenly accelerated and then decelerated? Hyperflexion Hyperextension Excessive rotation Vertical compression

Hyperextension

Which mechanism of spinal cord injury is caused by a sudden and forceful acceleration of the head forward? Hyperflexion Hyperextension Excessive rotation Vertical compression

Hyperflexion

Which term is used for a patient's report of decreased sensory sensation after a spinal cord injury (SCI)? Paraparesis Hypoesthesia Hyperesthesia Quadriparesis

Hypoesthesia

Which secondary spinal cord injury typically results from decreased amount of circulating blood? Ischemia Hemorrhage Local edema Hypovolemia

Hypovolemia

Intrathecal baclofen (ITB) Rationale

ITB may be prescribed to patients with spinal cord injuries to control severe muscle spasticity. However, this drug has adverse effects such as sedation, fatigue, dizziness, and changes in mental status. Lamotrigine, levetiracetam, and gabapentin are medications used to manage partial seizures , not to control severe muscle spasticity in patients with a spinal cord injury.

Which assessment finding indicates that the patient may have damage to the sacral spinal nerves? Inability to void Abdominal distention Positive Babinski reflex Paresthesias of the fingers

Inability to void

Repositioned Rationale

Log rolling the patient who has undergone spinal surgery is the best way to keep the spine in alignment. The patient who has undergone spinal surgery must remain straight.

Which term describes excessive inward curvature of the spine? Lordosis Scoliosis Spinal shock Spinal stenosis

Lordosis

Which medication would the nurse expect to be prescribed for a patient with a lumbosacral injury who has a blood pressure of 80/50 mm Hg? Dextran Tizanidine Atropine sulfate Methylprednisolone

Methylprednisolone

A halo fixator with a jacket is used to immobilize the spine of a patient after a vertebral fracture. Which action would the nurse use to monitor the patient for neurogenic shock? Check for severe bradycardia every 2 to 4 hours. Monitor the patient every hour for severe hypotension. Assess the patient's breath sounds every 2 to 4 hours. Verify that a finger can be inserted between the jacket and the patient's skin.

Monitor the patient every hour for severe hypotension.

Neurogenic Shock Rationale

Neurogenic shock occurs because of decreased circulating blood volume after a spinal cord injury. The patient must be monitored at least hourly for severe hypotension to assess for neurogenic shock.

The nurse is caring for a patient with a spinal cord injury resulting from a diving accident. The patient has a halo fixator and an indwelling catheter. The patient reports a severe headache and has an elevated blood pressure. Which medication would the nurse anticipate being prescribed? Nifedipine Ziconotide Methylprednisolone Dopamine hydrochloride

Nifedipine

A patient admitted to the intensive care unit after sustaining a cervical spinal cord injury in a motor vehicle crash is intubated and is receiving mechanical ventilation. The nurse notes a heart rate of 56 beats/min, blood pressure of 88/60 mm Hg, and warm, dry skin. Which action would the nurse take? Continue to assess the patient every 2 to 4 hours. Increase oxygen flow to the patient. Notify the health care provider of these findings immediately. Suction the patient to clear the airway of secretions.

Notify the health care provider of these findings immediately.

Which assessment would the nurse make to monitor a patient for fa embolism syndrome (FES) after lumbar spinal surgery? Observe for clear fluid on or around the dressing. Assess for abdominal distention, nausea, or vomiting. Monitor vital signs carefully for hypotension and tachycardia. Observe for pain or swelling around the wound site or the legs. Observe for chest pain, dyspnea, anxiety, and mental status changes. Note petechiae around the neck, upper chest, and conjunctiva.

Observe for chest pain, dyspnea, anxiety, and mental status changes. Note petechiae around the neck, upper chest, and conjunctiva.

Which assessment would the nurse make to monitor a patient for fat embolism syndrome (FES) after lumbar spinal surgery? Observe for clear fluid on or around the dressing. Assess for abdominal distention, nausea, or vomiting. Monitor vital signs carefully for hypotension and tachycardia. Observe for pain or swelling around the wound site or the legs. Observe for chest pain, dyspnea, anxiety, and mental status changes. Note petechiae around the neck, upper chest, and conjunctiva.

Observe for chest pain, dyspnea, anxiety, and mental status changes. Note petechiae around the neck, upper chest, and conjunctiva.

Which patient condition is associated with a lower thoracic spinal cord injury? Paraplegia Tetraplegia Hemiplegia Quadriplegia

Paraplegia

Paraplegia Rationale

Paraplegia is paralysis of the lower extremities that is seen in lower thoracic injuries.

Which term is used for weakness in a patient's arms and legs after a spinal cord injury (SCI)? Paraparesis Hypoesthesia Hyperesthesia Quadriparesis

Quadriparesis

A patient with a T6 spinal cord injury who is in the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action would the nurse take first? Raise the head of the bed. Insert a straight catheter. Check for fecal impaction. Loosen the patient's clothing.

Raise the head of the bed.

For which condition is a patient at high risk after a cervical spinal cord injury? Migraine headache Dementia Cardiac arrest Respiratory compromise

Respiratory Compromise

With which health care team member would the nurse collaborate to prevent the leading cause of death for a patient with a spinal cord injury? Physical therapist Nutritional therapist Respiratory therapist Occupational therapist

Respiratory Therapist

A patient reports difficulty swallowing, fatigue while talking, difficulty controlling crying or laughing, and weakness of the hands and arms. The laboratory shows increased serum creatine kinase. Which medication would the nurse anticipate being prescribed for this patient? Riluzole Fingolimod Clonazepam Propranolol hydrochloride

Riluzole

Riluzole Rationale

Riluzole is used for the treatment of amyotrophic lateral sclerosis (ALS). Difficulty swallowing, fatigue while talking, difficulty controlling crying or laughing, and weakness of the hands and arms are early clinical manifestations of ALS, and blood reports of patients with ALS may show increased creatine kinase. Fingolimod is used for the management of multiple sclerosis (MS). Propranolol hydrochloride and clonazepam are used for the treatment of cerebellar ataxia in patients who have MS.

Which term describes excessive sideways curvature of the spine? Lordosis Scoliosis Spinal shock Spinal stenosis

Scoliosis

Which technique would the health team teach to patients with cervical neck pain? Cough assist Sneeze assist Seated rowing Shoulder shrug Shoulder squeeze

Seated rowing Shoulder shrug Shoulder squeeze

A patient with a history of breast cancer reports sharp, piercing pain in the lower back that increased when coughing, straining, and lying flat. Which assessment finding would indicate the likely presence of spinal tumors in the lumbosacral region? Sexual dysfunction Horner syndrome Positive Babinski reflex Bladder and bowel dysfunction Decreased ankle and knee reflexes

Sexual dysfunction Bladder and bowel dysfunction Decreased ankle and knee reflexes

Which intervention would the nurse plan to prevent complications of immobility when caring for a patient with a complete spinal cord injury at the C7 level? Frequent ambulation Calorie increase by 50% Special pressure-relief devices Regular turning and repositioning Assessment of skin integrity at each repositioning

Special pressure-relief devices Regular turning and repositioning Assessment of skin integrity at each repositioning

Which condition involves complete but temporary loss of motor, sensory, reflex, and autonomic function? Spinal shock Spinal tumor Neurogenic shock Penetrating trauma

Spinal Shock

Which term describes back pain associated with narrowing of the spinal canal, nerve root canals, or intervertebral foramina? Lordosis Scoliosis Spinal shock Spinal stenosis

Spinal Stenosis

Spinal Shock Rationale

Spinal shock is characterized by a complete by temporary loss of motor, sensory, reflex, and function that often lasts less than 48 hours but may persist for several weeks. They are not indicators of permanent or fatal outcomes.

The nurse is monitoring a patient with an acute spinal cord injury (SCI). Which finding indicates an emergency? Stridor Garbled speech Increased urine output Pulse oximetry less than 95% Systolic blood pressure (SBP) less than 90 mm Hg Mean arterial pressure (MAP) less than 65 mm Hg

Stridor Garbled speech Pulse oximetry less than 95% Systolic blood pressure (SBP) less than 90 mm Hg Mean arterial pressure (MAP) less than 65 mm Hg

A patient is placed in a halo device to stabilize a cervical fracture. Which action would the nurse take? Tape a wrench to the vest. Reposition the patient by lifting the device. Adjust the screws holding the device in place. Insert a pencil beneath the vest to relieve itching.

Tape a wrench to the vest.

Methylprednisolone Rationale

The nurse would administer the prescribed dextran, which is a plasma expander. Dextran raises the capillary blood flow within the spinal cord. Tizanidine is a centrally acting skeletal muscle relaxant that is used to treat severe muscle spasms associated with upper motor neuron injuries. Atropine sulfate is administered to treat bradycardia when the pulse rate falls below 50 to 60 beats/min. Methylprednisolone is a glucocorticosteroid that is administered to reduce the inflammation associated with a lumbosacral injury.

T6 Rationale

The patient is experiencing autonomic dysreflexia, which can produce severe and rapidly occurring hypertension. Getting the patient to sit upright is the easiest and quickest action to take and has the most immediate chance of lowering blood pressure to the brain.

Halo Teaching Rationale

The patient with a halo fixation device should not drive because the device impairs vision.

Which statement about spinal cord injuries (SCIs) is correct? They are usually caused by falls. They occur most often in young males. They occur most often in black individuals. The thoracic level is the location of most injuries.

They occur most often in young males.

Medication Rationale

This patient is experiencing autonomic dysreflexia, which is a neurologic medical emergency that causes hypertension and bradycardia; nifedipine is given to treat elevated blood pressure. Dopamine hydrochloride is an inotropic agent used to treat severe hypotension. Methylprednisolone is a glucocorticoid and is not indicated because it may further increase blood pressure. Ziconotide is an N-type calcium channel blocker that is used to treat severe chronic back pain and failed back surgery syndrome (FBSS) and is also used for patients with cancer, acquired immune deficiency syndrome (AIDS), and unremitting pain from other nervous system disorders.

Halo Device Rationale

To ensure the patient's safety, a special wrench is needed to loosen the vest in emergencies such as cardiopulmonary arrest. The wrench should be taped to the vest for consistent accessibility and ease of use.

A patient sustains a C8 spinal cord injury and is experiencing impaired motor function. Which action is the patient unlikely able to perform? To form a fist To pull arms against resistance To breathe spontaneously To shrug the shoulders against pressure

To form a fist

Vehicle Crashes Rationale

Trauma is the leading cause of SCIs, with more than a third resulting from vehicle crashes.

Which type of trauma is the leading cause of spinal cord injuries (SCIs)? Falls Vehicle crashes Gunshot wounds Sport-related accidents

Vehicle crashes

Which mechanism of spinal cord injury may result from a diving accident or a jump in which a person lands on the feet? Hyperflexion Hyperextension Excessive rotation Vertical compression

Vertical Compression