Spinal Cord Injury NCLEX Questions

One month after a spinal cord injury, which finding is most important for you to monitor? A. Bladder scan indicates 100 mL. B. The left calf is 5 cm larger than the right calf. C. The heel has a reddened, nonblanchable area. D. Reflux bowel emptying.

B. The left calf is 5 cm larger than the right calf. Deep vein thrombosis is a common problem accompanying spinal cord injury during the first 3 months. Pulmonary embolism is one of the leading causes of death. Common signs and symptoms are absent. Assessment includes Doppler examination and measurement of leg girth. The other options are not as urgent to deal with as potential deep vein thrombosis.

18. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. When the nurse develops a plan of care for this problem, which nursing action will be most appropriate? a. Teaching the patient how to self-catheterize b. Assisting the patient to the toilet q2-3hr c. Use of the Credé method to empty the bladder d. Catheterization for residual urine after voiding

Correct Answer: A Rationale: Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence. Cognitive Level: Application Text Reference: p. 1605 Nursing Process: Planning NCLEX: Physiological Integrity

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which of the following findings is of most concern to the nurse? a. SpO2 of 92% b. HR of 42 beats/min c. BP of 88/60 d. loss of motor and sensory function in arms and legs

b. HR of 42 beats/min Rationale: Neurogenic shock associated with cord injuries above the level of T6 greatly decrease the effect of the sympathetic nervous system, and bradycardia and hypotension occur. A heart rate of 42 is not adequate to meet oxygen needs of the body, and while low, the BP is not at a critical point. The O2 sat is ok, and the motor and sensory loss are expected.

17. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? a. Strict adherence to a bowel retraining program b. Keeping the linen wrinkle-free under the client c. Preventing unnecessary pressure on the lower limbs d. Limiting bladder catheterization to once every 12 hours

17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.

Which is most important to respond to in a patient presenting with a T3 spinal injury? A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute B. Deep tendon reflexes of 1+, muscle strength of 1+ C. Pain rated at 9 D. Warm, dry skin

A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. The loss of sympathetic nervous system innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options can be expected findings and are not as significant. Patients in neurogenic shock have pink and dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.

Which clinical manifestation do you interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses

A. Bradycardia Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output.

A patient has manifestations of autonomic dysreflexia. Which of these assessments would indicate a possible cause for this condition? Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. 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? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. 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.

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.

Correct Answer: 2 Rationale: 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 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? 1. paralysis 2. spinal shock 3. high cervical injury 4. 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.

A nurse is caring for a client who has a C4 spinal cord injury. which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

D. respiratory compromise Rationale: Using the airway, breathing and circulation priority framework, the greatest risk to the client with a SCI at the level of C4 is respiratory compromise secondary to involvement of the phrenic nerve. Maintainance of an airway and provision of ventilator support as needed is the priority intervention.