MSN 377: Spinal Cord Injury & Neurogenic Shock

29. The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse would be the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."

1. "This must be very hard for you. You're feeling worthless?" (1. Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings; the nurse should be a therapeutic listener.)

What can occur with cord lesions at or above T6?

Autonomic dysreflexia

A patient with a spinal cord injury at level C3-4 is being cared for in the ED. What is the priority assessment? A) Determine the level at which the patient has intact sensation. B) Assess the level at which the patient has retained mobility. C) Check blood pressure and pulse for signs of spinal shock. D) Monitor respiratory effort and oxygen saturation level.

D) Monitor respiratory effort and oxygen saturation level.

33. The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of lightheadedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.

4. Lower the head of the bed immediately. (For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.)

You are helping the patient with an SCI to establish a bladder-retraining program. What strategies may stimulate the patient to void? (Choose all that apply). A) Stroke the patient's inner thigh. B) Pull on the patient's pubic hair. C) Initiate intermittent straight catheterization. D) Pour warm water over the perineum. E) Tap the bladder to stimulate detrusor muscle.

A) Stroke the patient's inner thigh. B) Pull on the patient's pubic hair. D) Pour warm water over the perineum. E) Tap the bladder to stimulate detrusor muscle.

You are preparing a nursing care plan for the patient with SCI including the nursing diagnosis Impaired Physical Mobility and Self-Care Deficit. The patient tells you, "I don't know why we're doing all this. My life's over." What additional nursing diagnosis takes priority based on this statement? A) Risk for Injury related to altered mobility B) Imbalanced Nutrition, Less Than Body Requirements C) Impaired Adjustment to Spinal Cord Injury D) Poor Body Image related to immobilization

C) Impaired Adjustment to Spinal Cord Injury

What neurological deficits occur below T12?

Loss of motor control and sensation below the waist. Loss of bowel and bladder control.

What neurological deficits occur below L4?

Loss of motor control and sensation in parts of the the thighs and legs. Loss of bowel and bladder control.

What neurological deficits occur below L2?

Loss of motor control and sensation in the legs and pelvis. Loss of bowel and bladder control.

What neurological deficits occur below C8?

Loss of motor control and sensation to parts of the arms and hands. Loss of bowel and bladder control.

What neurological deficits occur below T6?

Loss of motor control below the mid-chest but with motor control in some parts of the arms and hands. Loss of bowel and bladder control.

What neurological deficits occur below C6?

Loss of motor function and sensation below the shoulders. Loss of bowel and bladder control.

What neurological deficits occur below C4?

Loss of motor function and sensation from the neck down, including independent respiratory and bowel and bladder control.

Which patient is at highest risk for a spinal cord injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) (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.)

28. The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.

1. Monitor the pulse oximetry reading. 3. Encourage coughing and deep breathing. 5. Administer intravenous corticosteroids. (1. Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, the nurse should determine how much oxygen is reaching the periphery. 2. A C6 injury would not affect the client's ability to chew and swallow, so pureed food is not necessary. 3. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. 4. Autonomic dysreflexia occurs during the rehabilitation phase, not the acute phase. 5. Corticosteroids are administered to decrease inflammation, which will decrease edema, and help prevent edema from ascending up the spinal cord, causing breathing difficulties.)

26. In assessing a client with a T12 SCI, which clinical manifestations would the nurse expect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.

1. No reflex activity below the waist. (Spinal shock associated with SCI represents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist; therefore, no reflex activity below the waist would be expected.)

34. The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.

1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. (This client has signs/symptoms of a respiratory complication and should be assessed first.)

27. The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.

2. Administer low-dose subcutaneous anticoagulants. (Deep vein thrombosis (DVT) is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox) helps prevent blood from coagulating, thereby preventing DVTs.)

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? 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

2. Assess for a full bladder. (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.)

The client is diagnosed with neurogenic shock. Which signs/symptoms should the nurse assess in this client? 1. Cool moist skin. 2. Bradycardia. 3. Wheezing. 4. Decreased bowel sounds.

2. Bradycardia. (The client will have bradycardia instead of tachycardia, which is seen in other forms of shock.)

32. The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.

2. Instruct the client to report reddened or irritated skin areas. (Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.)

36. The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.

2. Refer the client to the state rehabilitation commission. (The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.)

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. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

2. assessing the patient's skin integrity 4. administering pain medication 5. providing passive range of motion (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.)

31. The client with a C6 SCI is admitted to the emergency department complaining of a severe pounding headache and has a BP of 180/110. Which intervention should the emergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room. 3. Assess for bladder distention. 4. Administer a narcotic analgesic.

3. Assess for bladder distention. (This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.)

25. The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine, which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.

3. Assess the client's airway. (The nurse must maintain a patent air- way. Airway is the first step in resuscitation.)

35. Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.

3. Assist with bowel training by placing the client on the bedside commode. (The assistant can place the client on the bedside commode as part of bowel training; the nurse is responsible for the training but can delegate this task.)

Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion

3. Ineffective Airway Clearance (Ineffective Airway Clearance is the priority nursing diagnosis for this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.)

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? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

3. elevated blood pressure (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.)

30. The client is diagnosed with an SCI and is scheduled for a magnetic resonance imaging (MRI) scan. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. "Do you have trouble hearing?" 2. "Are you allergic to any type of dairy products?" 3. "Have you eaten anything in the last eight (8) hours?" 4. "Are you uncomfortable in closed spaces?"

4. "Are you uncomfortable in closed spaces?" (MRI scans are often done in a very confined space; many people who have claustrophobia must be medicated or even rescheduled for the procedure in an open MRI machine, which may be available if needed.)

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? 1. Remind the patient of her injury and try to comfort her. 2. Call the healthcare provider and get an order for radiologic evaluation. 3. Prepare the patient for surgery, as her condition is worsening. 4. Explain to the patient that this could be a common, temporary problem.

4. Explain to the patient that this could be a common, temporary problem. (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.)

A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoresis, and flushing of the face and neck. What action should you take first? A) Administer the ordered acetaminophen (Tylenol). B) Check the Foley tubing for kinks or obstruction. C) Adjust the temperature in the patient's room. D) Notify the physician about the change in status.

B) Check the Foley tubing for kinks or obstruction.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a MVA. Which of the following assessments would take priority? A. Neurological deficit. B. Pulse ox readings. C. The client's feelings about the injury. D. Bladder distension.

B. Pulse ox readings. (After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary.)

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Reflex emptying of the bladder. B. Positive reflexes. C. Hyperreflexia. D. Inability to elicit an Babinski's reflex.

D. Inability to elicit an Babinski's reflex. (Resolution of spinal cord shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.)

While in the ER, a client with C8 tetraplegia develops a BP of 80/40, pulse 48, RR 18. The nurse suspects which of the following conditions? A.) Autonomic dysreflexia. B.) Pulmonary embolism. C.) Hemorrhagic shock. D.) Neurogenic shock.

D.) Neurogenic shock. (Symptoms of neurogenic shock include: hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion.)