Spinal Cord Injury

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care will be followed?Select all that apply. 1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 3. The patient will be placed on a ventilator. 4. The head of the bed will be elevated. 5. The patient's head will be secured with a belt or tape secured to the stretcher.

1. Immobilize the neck using rolled towels or a cervical collar. 2. The patient will be placed in a supine position 5. The patient's head will be secured with a belt or tape secured to the stretcher. n the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent movement are all basic guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be considered after admittance to the hospital.

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

1. autonomic dysreflexia 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.

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 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.

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

2. kinked catheter tubing 5. fecal impaction 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.

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

2. spinal shock 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 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.

Which of the following nursing actions is appropriate for preventing skin breakdown in a patient who has recently undergone a laminectomy? 1. Provide the patient with an air mattress. 2. Place pillows under patient to help patient turn. 3. Teach the patient to grasp the side rail to turn. 4. Use the log roll to turn the patient to the side.

4. Use the log roll to turn the patient to the side. A patient who has undergone a laminectomy needs to be turned by log rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but the patient still needs to be turned frequently. Placing pillows under the patient can help take pressure off of one side but the patient still needs to change positions often. Teaching the patient to grasp the side rail will cause the spine to twist, which needs to be avoided.

he nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." B) "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." C) "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." D) "The sudden, severe headache increases muscle tone and can cause further nerve damage."

A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski's reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities

A) Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this? A) Baclofen (Lioresal) B) Dexamethasone (Decadron) C) Mannitol (Osmitrol) D) Phenobarbital (Luminal)

A) Baclofen (Lioresal) Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A) Change the patient's position frequently. B) Provide a high-protein diet. C) Provide light massage at least daily. D) Teach the patient deep breathing and coughing exercises.

A) Change the patient's position frequently. Frequent position changes are among the best preventative measures against pressure ulcers. A high-protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A) Check the patient's indwelling urinary catheter for kinks to ensure patency. B) Lower the HOB to improve perfusion. C) Administer analgesia. D) Reassure the patient that headaches are expected after spinal cord injuries.

A) Check the patient's indwelling urinary catheter for kinks to ensure patency. A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patient's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A) Ensure that the player is not moved. B) Obtain the player's vital signs, if possible. C) Perform a rapid assessment of the player's range of motion. D) Assess the player's reflexes.

A) Ensure that the player is not moved. At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the patient's vital signs. It would be inappropriate to test ROM or reflexes.

A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP

A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.

A) Urinary retention can have serious consequences in patients with SCIs. Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A) Young age B) Frequent travel C) African American race D) Male gender E) Alcohol or drug use

A) Young age D) Male gender E) Alcohol or drug use

When caring for a patient who experienced a T2 spinal cord transection 24 hours ago, which collaborative and nursing actions will the nurse include in the plan of care (select all that apply)? a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Maintain a warm room temperature e. Administration of H2 receptor blockers

ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.

In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patients head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).

ANS: D, C, B, A, E The first action should be to prevent further injury by stabilizing the patients spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises

B) Applying thigh-high elastic stockings It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A) Respiratory distress and projectile vomiting B) Bradycardia and hypertension C) Tachycardia and agitation D) Third-spacing and hyperthermia

B) Bradycardia and hypertension Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia.

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A) Complete the pin site care to decrease risk of infection. B) Notify the neurosurgeon of the occurrence. C) Stabilize the head in a lateral position. D) Reattach the pin to prevent further head trauma.

B) Notify the neurosurgeon of the occurrence. If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A) Prepare to transfuse packed red blood cells. B) Prepare for interventions to increase the patient's BP. C) Place the patient in the Trendelenberg position. D) Prepare an ice bath to lower core body temperature.

B) Prepare for interventions to increase the patient's BP. Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A) Risk for impaired skin integrity B) Risk for injury C) Risk for autonomic dysreflexia D) Risk for suffocation

B) Risk for injury If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously

C) Ineffective breathing patterns related to weakness of the intercostal muscles A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day

C) Initiating (ROM) exercises as soon as possible after the injury Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowler's position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.

C) Perform passive ROM exercises as ordered. Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the patient's risk of muscle spasticity.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A) Epidural hemorrhage B) Hypertensive emergency C) Spinal shock D) Hypovolemia

C) Spinal shock In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents

D) Motor vehicle accidents

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A) The patient will be unable to use a wheelchair. B) The patient will be unable to swallow food. C) The patient will be continent of urine, but incontinent of bowel. D) The patient will require full assistance for all aspects of elimination

D) The patient will require full assistance for all aspects of elimination Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to swallow. The patient will be capable of using an electric wheelchair.

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A) The patient received a blood transfusion. B) The patient's analgesia regimen was recent changed. C) The patient was not repositioned during the night shift. D) The patient's urinary catheter became occluded.

D) The patient's urinary catheter became occluded. A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood transfusions are unlikely causes.

Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion

b. Assessment of respiratory rate and effort Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patients respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.

The patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Cred method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

b. Instruct the patient how to self-catheterize. Because the patients 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 Cred method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patients incontinence.

A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patients comments. d. Reassure the patient about the competence of the nursing staff.

b. Request that the patient provide input for the plan of care. The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patients input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patients anger. Ignoring the patients comments will increase the patients anger and sense of helplessness.

The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury

b. function of both arms should be retained. The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.

When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.

b. push a manual wheelchair on a flat surface. The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.

A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, I have a pounding headache and I feel sick to my stomach. Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider.

c. Assess the blood pressure (BP). The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patients health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.

Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough effort.

c. Assist in planning a prescribed bowel program. Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury

c. Hypotension, bradycardia, and warm, pink extremities Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.

A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patients mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.

c. push upward on the epigastric area as the patient coughs. Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patients ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurses first action.

A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally intubated. The nurse identifies this pathophysiologic response as caused by a. increased vasomotor tone after injury b. a temporary loss of sensation and flaccid paralysis below the level of injury c. loss of parasympathetic nervous system innervation resulting in vasoconstriction d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation

d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation