Med Surg Chapter 29: Spinal Cord Injury

6. What technique should the nurse implement to move the impaired legs of a patient with an SCI to avoid stimulation muscle spasm? a. Firmly grasping the calf muscle and the thigh muscle b. Manipulating the limb by supporting the knee and ankle joints c. Holding the foot upright and slowly dragging the limb into position d. Requesting assistance to support the calf and thigh

ANS: B Undue muscle stimulation can cause spasticity. Using the joint locations to support limbs when repositioning them reduces likelihood of spasticity. DIF: Cognitive Level: Application REF: p. 516 OBJ: 3 TOP: Spasticity KEY: Nursing Process Step: Implementation

33. A nurse refers to the _____ to assess the extent of sensory loss and specific nerve root enervation.

ANS: dermatome chart The assessment of the level and extent of sensory loss and, consequently, the affected nerve roots involved can be performed with the assistance of a dermatome chart. DIF: Cognitive Level: Knowledge REF: p. 521 OBJ: 6 TOP: Dermatome Chart KEY: Nursing Process Step: Assessment

18. Which intervention by a nurse is effective in the prevention of autonomic dysreflexia in the patient with an SCI? a. Ensure patency of the urinary catheter. b. Give warm baths to the patient to stimulate vasodilation. c. Keep lighting at a minimum to reduce stimulation. d. Offer the patient four or five small meals daily.

ANS: A A distended bladder, constipation, and sudden jarring can all set off autonomic dysreflexia. Vagal stimulation retards vasodilation. The number and size of meals have no affect on preventing this syndrome. DIF: Cognitive Level: Application REF: p. 523 OBJ: 6 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Planning

15. A patient is receiving methylprednisolone. What purpose should the nurse explain this drug has in treating a patient with an SCI? a. Reduces spinal cord cellular damage b. Counteracts spinal shock c. Increases blood supply to the injured cord d. Enhances sexual function

ANS: A Methylprednisolone, if given within the first 8 hours of the injury, can significantly reduce cellular damage to the cord. DIF: Cognitive Level: Knowledge REF: p. 519 OBJ: 4 TOP: Methylprednisolone KEY: Nursing Process Step: Implementation

11. A paraplegic patient excitedly reports seeing his foot move when he was being turned. How is this phenomenon best explained? a. Reflexive movement b. Return of motor function c. Early symptom of autonomic dysreflexia d. Result of hypertonicity of the muscle

ANS: A Reflexive action is a movement that does not require communication to the brain via the spinal cord. DIF: Cognitive Level: Comprehension REF: p. 511 OBJ: 5 TOP: Reflexive Motion KEY: Nursing Process Step: Assessment

21. A nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier. What action should the nurse implement? a. Continue to monitor. b. Inform the charge nurse. c. Perform intermittent catheterizations. d. Turn the patient to the right side.

ANS: A The nurse should continue to monitor the patient for urine output. Two hours is too soon to expect a continent patient to void. Informing the charge nurse and catheterization are not necessary. Turning this patient to the side is contraindicated. DIF: Cognitive Level: Application REF: p. 527 OBJ: 8 TOP: Postoperative Care for Laminectomy KEY: Nursing Process Step: Implementation

28. What has occurred in the past 10 years to enhance rehabilitation of individuals with SCIs? (Select all that apply.) a. Technologically advanced assistive aids b. Rehabilitation personnel c. Development of trauma centers d. Health insurance e. Rapid transport of victims

ANS: A, C, E New assistive aids, the development of decentralized trauma centers, and the rapid transport of victims have all increased the potential for rehabilitation. Rehabilitation personnel and health insurance are not new. DIF: Cognitive Level: Knowledge REF: p. 509 OBJ: 7 TOP: Enhanced Rehabilitation Potential KEY: Nursing Process Step: Implementation

7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should his score be interpreted? a. Weak contraction b. Muscle movement when supported c. Active muscle movement without support d. Full, active range-of-motion exercises against resistance

ANS: B A 2 on the muscle-grading scale means that muscular movement is observed when the limb is supported. DIF: Cognitive Level: Comprehension REF: p. 520 OBJ: 2 TOP: Neurologic Examination KEY: Nursing Process Step: Assessment

12. After spinal shock has been resolved, an indwelling catheter is removed. What way should the nurse expect this patient to empty the bladder? a. Manual expression (Credé method) b. Spontaneous reflexive action c. Normal voluntary control d. Self-catheterization

ANS: B After spinal shock resolves, spasticity of the bladder causes spontaneous emptying. DIF: Cognitive Level: Comprehension REF: p. 516-517 OBJ: 6 TOP: Bladder Control KEY: Nursing Process Step: Planning

3. Which assessment would indicate the resolution of spinal shock? a. Extension and rigidity in affected limbs b. Spastic involuntary movements in affected limbs c. Tingling and burning in affected limbs d. Voluntary purposeful movements of affected limbs

ANS: B Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock. DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3 TOP: Resolution of Spinal Shock KEY: Nursing Process Step: Assessment

1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra? a. Last thoracic b. Second lumbar c. First sacral d. Coccygeal

ANS: B The cord starts at the brainstem and extends to the second lumbar vertebra. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A TOP: Anatomy and Physiology of the Central Nervous System (CNS) KEY: Nursing Process Step: N/A

14. What is the major advantage of the halo device over the Gardner-Wells tongs? a. Separates the cervical vertebrae b. Allows the patient out of bed c. Aligns the cervical spine d. Relieves pain

ANS: B The halo device and the Gardner-Wells tongs do exactly the same thing in terms of separation and alignment. The only advantage of the halo device is the mobility it allows. Neither traction modality specifically relieves pain. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 4 TOP: Halo Device KEY: Nursing Process Step: Implementation

8. Which technique of opening the airway in the newly admitted patient with an SCI is the most appropriate? a. Chin lift b. Head tilt c. Jaw thrust d. Neck flexion

ANS: C The jaw thrust does not require spinal movement. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 6 TOP: Opening Airway KEY: Nursing Process Step: Implementation

20. The family members of a patient with an SCI, who is in the rehabilitation phase, wants to take the patient outdoors for a visit. It is 90° F outside and very humid. What should the nurse suggest? a. Do not go outside at all but remain in the hospital. b. Take a spray bottle to spray water to cool the patient by evaporation. c. Take a light sweater to insulate the patient. d. Have the patient drink at least 32 oz of water during the outing.

ANS: B Water will evaporate and cool the patient, similar to perspiration. DIF: Cognitive Level: Application REF: p. 525 OBJ: 3 TOP: Impaired Thermal Regulation KEY: Nursing Process Step: Planning

29. What changes occur with the intervertebral disks in older adults that increase the risk of injury? (Select all that apply.) a. Fill with calcium deposits b. Are less shock absorbent c. Are herniated d. Enlarge and swell e. Lose water

ANS: B, E Age affects the water content in intervertebral disks, which makes them less able to absorb shock. Herniation and swelling can occur at any age. Disks do not fill with calcium. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A TOP: Age-Related Changes to Intervertebral Disks KEY: Nursing Process Step: Implementation

30. Before taking a magnetic resonance image (MRI), a patient asks why metal objects and the MRI machine are such concerns. What is the best explanation by the nurse regarding the MRI machine? (Select all that apply.) a. Causes metal objects to spark, similar to a microwave b. Deactivates the battery in a pacemaker c. Causes metal to heat up and burn the patient d. Does not transmit clear data if metal is present e. Attracts any metal into the MRI chamber

ANS: B, E The magnetic field will deactivate the batteries in a pacemaker and will also attract any metal object into the MRI chamber. DIF: Cognitive Level: Knowledge REF: p. 513 OBJ: 2 TOP: Metal Precautions with MRI KEY: Nursing Process Step: Implementation

19. A nurse tells a patient with quadriplegia that he is being treated with intravenous (IV) drugs because this method is more effective than intramuscularly (IM). What explanation should the nurse provide about IM medications to explain to the patient why they are less effective than IV? a. Too concentrated b. Too irritating to poorly perfused tissue c. Not absorbed well below the level of the injury d. Too small a dose to be effective

ANS: C A patient with quadriplegia has a high cervical lesion, which causes nearly the entire vascular tree to have poor perfusion. This condition would make absorption of medications from the tissues unpredictable. DIF: Cognitive Level: Comprehension REF: p. 523 OBJ: 4 TOP: Injections for the Patient with an SCI KEY: Nursing Process Step: Implementation

25. The family of a patient with an SCI is concerned with the lack of bowel function 2 days after the injury. What is the best response by the nurse? a. "Because of his injury, he will always need to have enemas for bowel evacuation." b. "Medical management is delaying bowel action because it places pressure on the injury." c. "Bowel function should return in approximately 3 days after the accident." d. "We'll just have to wait and see if bowel action returns this week."

ANS: C Bowel action usually returns with peristalsis on the third day after the accident. The bowel responds to dilation from the content in the bowel and moves without voluntary action from the patient. DIF: Cognitive Level: Application REF: p. 524 OBJ: 1 TOP: Impaired Bowel Function KEY: Nursing Process Step: Implementation

27. What should a nurse encourage a patient with an SCI to do after a computed tomography (CT) scan? a. Sit up at a 30-degree angle. b. Prevent chilling. c. Drink plenty of water. d. Avoid bearing down.

ANS: C Fluids are pushed after a CT scan to flush the contrast media through the kidneys. DIF: Cognitive Level: Application REF: p. 512 OBJ: 2 TOP: Post-CT Scan Intervention KEY: Nursing Process Step: Implementation

17. What should be the immediate intervention when a nurse recognizes autonomic dysreflexia in the patient with an SCI? a. Flex the patient's legs using the knee gatch of the bed. b. Cool the patient with alcohol solution. c. Raise the head of the bed to at least 45 degrees. d. Administer oxygen per mask.

ANS: C Raising the head of the bed reduces the BP. Flexed legs, cooling, and oxygen will not alleviate the syndrome. DIF: Cognitive Level: Application REF: p. 523 OBJ: 6 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Implementation

22. Which statement made by a male patient with an SCI could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction, related to altered body function"? a. "I know I will never have a sexual relationship again." b. "I need some suggestions as to how to direct my sexual energy into gardening or painting . . . or just anything." c. "Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?" d. "I think that after a while I will be able to have sexual relationships just like I had before my accident."

ANS: C Seeking help from a counselor indicates an acceptance of learning alternative techniques. Remarks eliminating all possibilities of a sexual relationship are defeatist remarks and are not positive. However, a patient should realize that his or her sexual relationships will alter as a result of the SCI. DIF: Cognitive Level: Analysis REF: p. 525 OBJ: 7 TOP: Sexual Dysfunction KEY: Nursing Process Step: Evaluation

2. On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is permanent. What is the best response by the nurse? a. "Yes. In all likelihood, the paralysis is probably permanent." b. "No. Significant recovery of function should occur in a few days." c. "It is too early to tell. When the spinal shock subsides, we will know more." d. "You should talk to your physician about things of that nature."

ANS: C Spinal shock caused by swelling may last from a few days to months, clouding the issue of the true extent of the injury. DIF: Cognitive Level: Application REF: p. 516 OBJ: 3 TOP: Spinal Shock KEY: Nursing Process Step: Implementation

23. What should a nurse emphasize regarding the rehabilitation of the patient with an SCI? a. Rehabilitation is usually achieved within a few months after stabilization. b. Rehabilitation will return the patient with an SCI to the preaccident functional level. c. Rehabilitation focuses on adjustments necessary to reenter society and the workplace. d. Rehabilitation completely targets self-care.

ANS: C The goals of rehabilitation are modification of lifestyle, as well as expectations and adjustments, necessary to attain the highest level of independence possible. DIF: Cognitive Level: Comprehension REF: p. 526 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Planning

5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance of the nurse's hand. The patient is unable to perform this action. Where does this assessment confirm that cord damage has occurred? a. C4 to C5 b. L2 to L4 c. L5 d. S1

ANS: C The muscle group that controls the feet is at L5. DIF: Cognitive Level: Comprehension REF: p. 515-517 OBJ: 2 TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment

4. Which assessment leads the emergency department nurse to suspect that a patient's spinal cord injury (SCI) is below C4? a. Voluntary eye movement b. Ability to blink the eyelids c. Unlabored respiration d. Ability to make a facial grimace

ANS: C The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal function for ventilation. DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3 TOP: Level of SCIs KEY: Nursing Process Step: Assessment

31. A nurse is caring for a despondent young female patient with an SCI at C5. The patient verbalizes concern regarding sexual dysfunction. What should the nurse assure this patient she can still experience? (Select all that apply.) a. Vaginal sensation b. Vaginal orgasm c. Normal menses d. Intercourse e. Children

ANS: C, D, E Intercourse, normal menses, and childbirth are all possible for a woman with a C5 lesion, but no vaginal sensation occurs. Orgasm is possible but not vaginally stimulated. DIF: Cognitive Level: Comprehension REF: p. 517 OBJ: 3 TOP: Risk for Sexual Dysfunction KEY: Nursing Process Step: Implementation

26. What should a nurse explain when a patient with an SCI inquires what the physician means by a cone-down? a. A cone is surgically placed over the spine to protect the cord. b. Marks will be placed on either side of the injury to mark the area. c. A cone-shaped wedge of bone will be placed between the vertebrae. d. A detailed radiographic image will be taken of the spinal injury.

ANS: D A cone-down radiographic image provides a very detailed picture of the lesion. DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: 2 TOP: Cone-Down X-Ray KEY: Nursing Process Step: Implementation

24. What should a nurse include in a patient's plan of care when considering interventions for the outcome of prevention of contractures in a patient with an SCI? a. Apply cold wraps to the limbs twice a day. b. Perform full ROM exercises every 2 hours. c. Use significant tactile stimuli each shift. d. Apply splints to the limbs.

ANS: D Applying splints will reduce contractures. Cold application, agitation of the limb with ROM exercises too frequently, and tactile stimuli increase spasticity. DIF: Cognitive Level: Application REF: p. 524 OBJ: 7 TOP: Rehabilitation KEY: Nursing Process Step: Planning

16. A patient with an SCI begins to have seizures, and the blood pressure (BP) rises rapidly to 210/160 mm Hg. Which is the third indicator of the syndrome of autonomic dysreflexia? a. Profuse vomiting b. Hives on face and neck c. Excessive urine output d. Bradycardia

ANS: D Bradycardia, hypertension, and seizure are the three signs of autonomic dysreflexia. DIF: Cognitive Level: Knowledge REF: p. 516 OBJ: 3 TOP: Autonomic Dysreflexia KEY: Nursing Process Step: Assessment

9. Brown-Séquard syndrome results in which neurologic deficit? a. Bilateral loss of pain sensation below the level of injury b. Bilateral loss of temperature and motor function below the level of injury c. Motor and sensory loss in the upper extremities only d. Ipsilateral loss of motor function and contralateral loss of pain sensation and temperature

ANS: D Brown-Séquard syndrome is a hemisection of the cord resulting in ipsilateral motor loss and contralateral loss of pain and temperature. DIF: Cognitive Level: Knowledge REF: p. 515 OBJ: 3 TOP: Brown-Séquard Syndrome KEY: Nursing Process Step: Assessment

13. A distressed family member asks about the purpose of the Gardner-Wells tongs. Which is the most helpful explanation by the nurse regarding the action of Gardner-Wells tongs? a. Compress the cervical vertebrae. b. Immobilize the head. c. Allow the patient to be moved out of bed. d. Align the cervical vertebrae.

ANS: D The Gardner-Wells tongs are secured to the skull to separate and align the cervical vertebrae, but they do not immobilize the head. When the tongs are in place, the patient is bedridden. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 4 TOP: Gardner-Wells Tongs KEY: Nursing Process Step: Implementation

32. A home health nurse encourages the family of a patient with an SCI to use the assisted cough technique. What does this technique require the caregiver to do? (Select all that apply.) a. Assist the patient to inhale a bronchodilator spray and then cough. b. Forcefully press on patient's back below the rib cage while the patient is in the prone position. c. Assist the patient to lean forward, breathe deep, and then cough. d. Apply pressure to diaphragm as the patient coughs. e. Slap the patient on upper back while the patient is in the prone position.

ANS: D To assist the patient with an SCI to cough, the caregiver applies pressure on the diaphragm as the patient attempts to cough after having taken a deep breath. DIF: Cognitive Level: Comprehension REF: p. 523 OBJ: 6 TOP: Assisted Cough KEY: Nursing Process Step: Intervention

10. Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection? a. Manage a mechanical wheelchair with a joystick. b. Manage a mechanical wheelchair with hand control. c. Manage a specially equipped wheelchair. d. Manage an ordinary wheelchair.

ANS: D Upper extremity mobility and enhanced hand grip allow the use of an ordinary wheelchair by an individual with a C8 level SCI. DIF: Cognitive Level: Application REF: p. 515 OBJ: 6 TOP: Goal for Rehabilitation KEY: Nursing Process Step: Planning