Spinal Cord Injury Practice Questions

When assessing the client with a cord transection above T5 for possible complications, Which complication is least likely to occur? A. Diarrhea B. Paralytic ileus C. Stress ulcers D. Intra-abdominal bleeding

A. Diarrhea

A nurse is planning care for a client who has a SCI involving T12 fracture 1 week ago. The client has no muscle control over the lower limbs, bowel, or bladder. Which of the following should be the nurses highest priority? A. Prevention of further damage to the spinal cord B. prevention of contractors of the lower extremities C. prevention of skin breakdown of areas that lack sensation D. Prevention of postural hypotension when placing the client in a wheelchair

A. Prevention of further damage to the spinal cord

A client with a cervical spine injury has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? Select all that apply. A. checking the clients skin for pressure from the device B. Assessing the clients neurologic status for signs of infection C. Observing the halo insertions sites for signs of infections D. Cleaning the halo insertion sites with hydrogen peroxide E. Developing the nursing plan of care for the client

A. checking the clients skin for pressure from the device C. Observing the halo insertions sites for signs of infections D. Cleaning the halo insertion sites with hydrogen peroxide

A nurse is caring for a client who experienced a cervial spine injury. 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? A. condom Catheter B. Intermittent urinary catherization C. Credes method D. Indwelling urinary catheter

A. condom Catheter

A client with an SCI reports sudden severe throbbing headache that started a shot time ago. Assessment of the client reveals increased BP 168/94 and decreased HR 48, diaphoresis and flushing of the face and neck. What action should you take first? A. Administer acetaminophen B. Check the foley tubing for kinks or obstruction C. Adjust the temperature in the clients room D. Notify the physical about the change in status

B. Check the foley tubing for kinks or obstruction

A nurse is caring for a client who has a spinal cord injury who reports severe headache and is sweating profusely. Vital signs include BP 220/110 and apical HR 54/min. Which of the following actions should the nurse take first? A. Notify the provider B. Sit the client upright in bed C. Check the urinary catheter for blockage D. Administer antihypertensive medication.

B. Sit the client upright in bed

When the client has a cord transection at T4, the nurse should focus the assessment on A. renal status B. Vascular status C. Gastrointestinal function D. Biliary function

B. Vascular status

You are floated from the ED to the neurologic floor. Which action should you delegate to the UAP when providing nursing care for a client with an SCI? A.Assessing the client's respiratory status every 4 hours B.Taking the client's vital signs and recording every 4 hours C.Monitoring the client's nutritional status, including calorie counts D.Instructing the client how to turn, cough, and breathe deeply every 2 hours

B.Taking the client's vital signs and recording every 4 hours

During the period of Spinal shock, the nurse should expect the clients bladder function to be: A. spastic B. Normal C. Atonic D. Uncontrolled

C. Atonic

The nurse is caring for a client with spinal cord injury. The client is experiencing blurred vision and has a BP of 204/102 mm Hg. what should the nurse do first? A. Position client on the left side B. Control the environment by turning the lights off and decreasing stimulation for the client C. Check the clients bladder for distention D. Administer pain medication

C. Check the clients bladder for distention

When planning to move a person with a possible spinal cord injury , the nurse should direct the team to. A. Limit movement of the arms by wrapping them next to the body B. Move the person to gently help reduce pain C. Immobilize the head and neck to prevent further injury D. Cushion the back with pillows to ensure comfort

C. Immobilize the head and neck to prevent further injury

The client with spinal cord injury asks tej nurse why the dietician has recommended to decrease the total daily intake of calcium. Which response by the nurse would provide the most accurate information? A. " excessive intake of dairy products makes constipation more common." B. " immobility increases calcium absorption from the intestine." C." lack of weight bearing causes demineralization of the long bones." D. "Dairy products likely contribute to weight gain."

C." lack of weight bearing causes demineralization of the long bones."

After 1 month of therapy, the client in spinal shock begins to experience muscle spasms in the legs and calls the nurse in excitement to report the leg movement. Which response by the nurse would be the most accurat? A. " These movements indicate that the damaged nerves are healing." B. " this is a good sign. Keep trying to move all the affected muscles." C. "lack of weigh bearing causes demineralization of the long bones". D. " the movements occur from the muscle reflexes that cannot be initiated or controlled by the brain."

D. " the movements occur from the muscle reflexes that cannot be initiated or controlled by the brain."

A client with an SCI at level C3-4 is being cared for in the ED. What is the priority assessment? A. Determine the level at which the client has intact sensation B. Assess the level at which the client has retained mobility C. Check blood pressure and pulse for signs of spinal shock D. Monitor resp. effort and oxygenation saturation level

D. Monitor resp. effort and oxygenation saturation level

A nurse is caring for a client who experienced a cervicial spine injury 24 hours ago. Which of the following types of prescribed medication should the nurse clarify with the provider? A. Glucocorticoids B. Plasma expanders C. H2 antagonists D. Muscle relaxants

D. Muscle relaxants

A nurse is caring for a client who has C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following complications. A. Neurogenic Shock B. Paralytic Ileus C. Stress ulcer D. Respiratory compromise

D. Respiratory compromise