Med Surg Chapter 43 part 1

Which assessment findings alert the nurse that a patient with a spinal cord injury is experiencing autonomic dysreflexia? Select all that apply.

Bradycardia Headache Hypertension Nasal stuffiness Patients experiencing autonomic dysreflexia present with bradycardia, headache, hypertension, and nasal stuffiness. They have flushing warm skin, not cold and clammy skin.

Which statement about autonomic dysreflexia is accurate?

It can be caused due to a distended bladder. Autonomic dysreflexia refers to an excessive, uncontrolled sympathetic output that is caused due to a noxious stimulus. This stimulus often arises from a distended bladder. It is seen in upper spinal cord injuries (SCI) above the level of T6. Orthostatic hypotension may occur due to interruption of the sympathetic innervations caused by SCI. Autonomic dysreflexia involves excessive sympathetic output, and therefore causes severe hypertension. It also causes bradycardia, which is a decrease in heart rate.

Which statement about spinal cord tumors is correct?

These patients are managed primarily by surgery. Spinal cord tumors are managed primarily by surgery to remove as much of the tumor as possible. Spastic paralysis is more common, although flaccid paralysis may occur at times. A positive Babinski's sign is a key thoracic manifestation. In this condition, patients often lose control over their urinary bladder before losing bowel control.

. Which statement about spinal cord injuries is correct?

They occur mostly in young males Almost 80% of spinal cord injuries (SCIs) occur in young males and the majority of them are Euro-Americans. Falls are likely the cause of SCIs in older adults; however, most SCIs are caused by trauma from motor vehicle crashes. Cervical SCIs are more common than thoracic and lumbosacral cord injuries.

Which type of spinal cord injury causes tearing of posterior ligaments and dislocation of vertebrae in the patient?

hyperflexion Hyperflexion injury occurs when the head is accelerated forward forcefully and suddenly, causing tearing of the posterior ligaments and vertebral dislocation. Axial loading injury occurs due to compression, in which the vertebrae shatter, and the pieces damage the spinal cord. Hyperextension injury occurs when the head is suddenly accelerated and then decelerated. This causes tearing of the anterior longitudinal ligament and fractures the intervertebral disks. Penetrating trauma injury is classified by the speed of the object at the local site

The nurse assesses a patient with a spinal cord injury. To assess motor function in the L2-L4 vertebrae, the nurse applies resistance and asks the patient to perform which motion?

Elevation of legs To assess L2-L4, the nurse should apply resistance and ask the patient to elevate the legs from the bed. Dorsiflexion of the feet is done to assess L5. Flexion of the feet is performed to assess S1. There is no indicated use for asking the patient to flex the knees against resistance.

Which type of tumor may include meningiomas as an example?

Extramedullary Meningiomas are found within the spinal dura but outside the spinal parenchyma; therefore, they are known as extramedullary tumors. Epidural tumors occur between the vertebrae and spinal dura. Intramedullary tumors are found within the spinal parenchyma. Secondary tumors are cancerous whereas meningiomas are noncancerous tumors.

Which assessment findings alert the nurse that a patient with a spinal cord injury is developing neurogenic shock? Select all that apply.

Hypotension Warm, dry skin The patient experiencing neurogenic shock exhibits severe hypotension and warm, dry skin. The patient would display bradycardia, not tachycardia. Pupillary dilation, projectile vomiting, and facial flushing are not symptoms of neurogenic shock.

Which assessment finding indicates the patient may have damage to the sacral spinal nerves?

Inability to void An inability to void may indicate damage to the sacral spinal nerves, which control the detrusor muscle of the bladder. Abdominal distention may occur due to the effects of anesthesia, but does not indicate sacral nerve damage. A positive Babinski's sign is indicative of nerve damage other than the sacral spinal nerve. Paresthesia of the fingers is not associated with damage to the spinal nerves.

In caring for a patient in the early postoperative period after anterior cervical diskectomy and fusion (ACDF), which nursing intervention is the priority?

Maintaining open airway The priority for care in the immediate postoperative period after an ACDF is maintaining an airway and ensuring the patient has no problems breathing. Maintaining cervical alignment, intravenous pain management, and strict intake and output are important nursing interventions, but are not the priority.

. A halo fixator with a jacket is used to immobilize the spine of a patient following a vertebral fracture. What nursing assessment monitors for neurogenic shock?

Monitor the patient every hour for severe hypotension Neurogenic shock occur due to decreased circulating blood volume following a spinal cord injury. The patient must be monitored at least hourly for severe hypotension to assess for neurogenic shock. The patient's breath sounds should be assessed every 2 to 4 hours to note if the airway is patent and ventilation is adequate. The patient should be monitored for severe bradycardia at least hourly to monitor for neurogenic shock. Inserting a finger between the jacket and the patient's skin ensures that the jacket is not causing pressure.

Which complications occur most commonly after conventional diskectomy, laminectomy, or spinal fusion? Select all that apply.

Nerve injury Dural tears The most common major complications of diskectomy, laminectomy, or spinal fusion are nerve injury and dural tears. Wound infection may occur, but is not related just to this type of surgery. Paralysis could occur, but is not common and is unlikely. Bowel perforation could occur with any abdominal surgery, but is not common to these surgeries. Encephalitis is not caused by surgery of any kind.

The nurse is monitoring a patient for major complications following lumbar spinal surgery. What assessments does the nurse make to monitor for fat embolism syndrome (FES)? Select all that apply.

Observe for chest pain, dyspnea, anxiety, and mental status changes Note petechiae around the neck, upper chest, and conjunctiva To assess for FES following lumbar spinal surgery, it is important to observe for chest pain, dyspnea, anxiety, and change in mental status of the patient. Petechiae around the neck, upper chest, buccal mucosa, and conjunctiva may also indicate FES. The presence of clear fluid on or around the dressing may indicate leakage of cerebrospinal fluid. Hypotension and tachycardia may indicate a fluid volume deficit. Abdominal distention, nausea, or vomiting would be present with a paralytic ileus rather than FES. Pain or swelling around the wound site or the legs may indicate an infection.`

What is the most common manifestation of a spinal cord tumor?

Pain at rest The most common problem in patients with a spinal cord tumor is non-mechanical back pain. Leg weakness, bowel incontinence, and hand grasp strength would depend upon the location of the spinal cord tumor.

What assessment finding is associated with a lower thoracic spinal cord injury?

Paraplegia Paraplegia is paralysis of the lower extremities that is seen in lower thoracic injuries. Tetraplegia is paralysis of all four extremities and is associated with cervical cord and upper thoracic injuries. Hemiplegia is paralysis of one side of the body and is associated with stroke. Quadriplegia is the same as tetraplegia, which is paralysis of all four extremities. Quadriplegia is associated with cervical cord and upper thoracic injuries.

Which major risk factor is associated with cervical spinal cord injury?

Respiratory distress The major risk factor associated with cervical spinal cord injury is respiratory compromise. The cervical spinal nerves innervate the phrenic nerve, controlling the diaphragm. Injury to the nerve causes the breathing disturbances. Migraine, dementia, and cardiac arrest are not the major risk factors associated with cervical spinal cord injury.

Which condition in a patient involves complete but temporary loss of motor, sensory, reflex, and autonomic function?

Spinal Shock Spinal shock occurs when the cord immediately responds to the injury. Patients with spinal shock have complete but temporary loss of motor, sensory, reflex, and autonomic function. Spinal cord tumor causes ischemia and infarction. Neurogenic shock causes hypoperfusion due to severe cord injury. Penetrating trauma causes local damage to the spinal cord.

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

c8 The patient is unable to grasp an object or form a fist if there is a spinal cord injury C8. If the injury is at C4-5, the patient has problems in shrugging the shoulders upward against resistance. If injury is at C5-6, the patient has problems in pulling up the arms against resistance. If the injury is at C7, the patient has problems in straightening his or her flexed arms against resistance.

The patient with a spinal cord injury at T2 is experiencing autonomic dysreflexia. Which intervention has the highest priority?

placing the patient in a sitting position Autonomic dysreflexia is an excessive, uncontrolled sympathetic output characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing; it must be promptly treated to prevent a hypertensive stroke. Placing the patient in a sitting position creates the effect of orthostatic hypotension to relieve hypertensive pressure on the brain, and is the very first priority. Administering hydralazine, loosening tight clothing, and assessing urinary catheter tubing are important interventions and should also be performed, but they are not the first priority.