Chapter 61: Peripheral Nerve and Spinal Cord Problems NCLEX

Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to the possibility of autonomic dysreflexia? A. Headache and rising blood pressure B. Irregular respirations and shortness of breath C. Decreased level of consciousness or hallucinations D. Abdominal distention and absence of bowel sounds

A. Headache and rising blood pressure Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic.

For a 65-year-old female patient who has lived with a T1 spinal cord injury for 20 years, which health teaching information should you emphasize? A. A mammogram is needed every year. B. Bladder function tends to improve with age. C. Heart disease is not common in persons with spinal cord injury. D. As a person ages, the need to change body position is less important.

A. A mammogram is needed every year. Health promotion and screening are important for the older patient with a spinal cord injury. Older adult women with spinal cord injuries should perform monthly breast examinations and yearly mammograms

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.

Which intervention should you perform in the acute care of a patient with autonomic dysreflexia? A. Urinary catheterization B. Administration of benzodiazepines C. Suctioning of the patient's upper airway D. Placement of the patient in the Trendelenburg position

A. Urinary catheterization Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. The patient should be positioned upright. Benzodiazepines are contraindicated, and suctioning is likely unnecessary.

In which order will the nurse perform the following actions when caring for a patient with possible C6 spinal cord trauma who is admitted to the emergency department? Put a comma and space between each answer choice (a, b, c, d, etc.) ____________________ a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Transfer the patient to radiology for spinal computed tomography (CT). e. Immobilize the patient's head, neck, and spine.

ANS: E, C, B, A, D The first action should be to prevent further injury by stabilizing the patient's spinal cord. 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.

When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion

ANS: A Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. The other actions also are appropriate but are not as important as assessment of respiratory effort

A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.

ANS: A 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 sustained a spinal cord injury a week ago becomes angry, telling the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which reaction by the nurse is best? a. Ask for the patient's input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patient's comments.

ANS: A The patient is demonstrating behaviors consistent with the anger phase of the mourning process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage and should be tolerated by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.

When caring for a patient who experienced a T1 spinal cord transsection 2 days 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. Avoidance of cool 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.

A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Credé method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.

ANS: B 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.

A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patient's arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.

ANS: B The patient with a T1 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.

A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.

ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.

When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patient's oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.

ANS: C Since 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 patient's 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 nurse's first action.

A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My head is throbbing, and I feel sick to my stomach." Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.

ANS: C 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 patient's 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. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used to prevent further increases in the BP.

After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and support the spouse's participation.

ANS: C The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.

patient has an incomplete right spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for left leg pain b. Assessment of the patient for left arm weakness c. Positioning the patient's right leg when turning the patient d. Teaching the patient to look at the left leg to verify its position

ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the right leg. Pain sensation will be lost on the patient's left leg. Left arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the left leg.

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

ANS: D Fecal impaction is a common stimulus for autonomic dysreflexia. The other actions may be included in the plan of care but will not reduce the risk for autonomic dysreflexia.

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

ANS: D 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.

What are the goals of rehabilitation for the patient with an injury at the C6 level (select all that apply)? A. Stand erect with leg brace B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair

B. Feed self with hand devices C. Drive an electric wheelchair D. Assist with transfer activities E. Drive adapted van from wheel chair Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability to assist with transfer and perform some self-care; feed self with hand devices; push wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent computer use with adaptive equipment; and needing attendant care only for 6 hours per day.

You are caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. What is this condition? A. Central cord syndrome B. Spinal shock syndrome C. Anterior cord syndrome D. Brown-Séquard syndrome

B. Spinal shock syndrome About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results in motor and sensory loss but not loss of reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

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.

What is most important action for a patient who has a suspected cervical spinal injury? A. Apply a soft foam cervical collar. B. Perform a neurologic check. C. Place the patient on a firm surface. D. Assess function of cranial nerves IX and X.

C. Place the patient on a firm surface. A patient with a suspected cervical spine injury should be immobilized with a hard collar and placed on a firm surface. This takes priority over any further assessment. A soft foam collar does not provide immobilization.

A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have the flu because he has a bad headache and nausea. What is your initial action? A. Call the physician. B. Check the patient's temperature. C. Take the patient's blood pressure. D. Elevate the head of the bed to 90 degrees.

C. Take the patient's blood pressure. Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion, bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and nausea. It is important to measure blood pressure when a patient with a spinal cord injury complains of a headache.

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? A. Impaired tissue integrity due to paralysis B. Impaired urinary elimination due to quadriplegia C. Ineffective coping due to the extent of trauma D. Ineffective airway clearance due to high cervical spinal cord injury

D. Ineffective airway clearance due to high cervical spinal cord injury Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although all of these options are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember the ABCs.

A patient is admitted to the intensive care unit (ICU) with a C7 spinal cord injury and diagnosed with Brown-Séquard syndrome. What would you most likely find on physical examination? A. Upper extremity weakness only B. Complete motor and sensory loss below C7 C. Loss of position sense and vibration in both lower extremities D. Ipsilateral motor loss and contralateral sensory loss below C7

D. Ipsilateral motor loss and contralateral sensory loss below C7 Brown-Séquard syndrome is a result of damage to one half of the spinal cord. This syndrome is characterized by a loss of motor function and position and vibratory sense, as well as vasomotor paralysis on the same side (ipsilateral) as the lesion. The opposite (contralateral) side has loss of pain and temperature sensation below the level of the lesion.

A patient is admitted to the hospital with a C4 spinal cord injury after a motorcycle collision. The patient's blood pressure is 83/49 mm Hg and pulse is 39 beats/minute. He remains orally intubated. What is the cause of this pathophysiologic response? A. Increased vasomotor tone after the 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 eurogenic shock results from loss of vasomotor tone caused by injury, and it is characterized by hypotension and bradycardia. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and a decreased cardiac output. These effects usually are associated with a cervical or high thoracic injury (T6 or higher).

Which patient should be assigned to the experienced registered nurse on a neurologic floor? A. Patient with trigeminal neuralgia reporting facial pain rated at 10 B. Patient with Bell's palsy with unilateral facial droop C. Patient after surgical removal of a spinal cord tumor who is scheduled for discharge tomorrow D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department

D. Patient with traumatic injury to the cervical spinal cord who was admitted today from the emergency department The patient with the cervical spinal cord injury is potentially the most unstable and needs an experienced, professional nurse.

You are caring for a patient admitted 1 week earlier with an acute spinal cord injury. Which assessment finding alerts you to the presence of autonomic dysreflexia? A. Tachycardia B. Hypotension C. Hot, dry skin D. Throbbing headache

D. Throbbing headache Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system, which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.

The patient arrives in the emergency department from a motor vehicle accident, during which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is shattered. What action is most important for you to do? A. Determine if the patient lost consciousness. B. Assess the Glasgow Coma Scale (GCS) score. C. Obtain a set of vital signs. D. Use a logroll technique when moving the patient.

D. Use a logroll technique when moving the patient. When the head hits the windshield with enough force to shatter it, you must assume neck or cervical spine trauma occurred and you need to maintain spinal precautions. This includes moving the patient in alignment as a unit or using a logroll technique during transfers. The other options are important and are done after spinal precautions are applied.

The nurse performs discharge teaching for a 34-year-old male patient with a T2 spinal cord injury resulting from a construction accident. Which statement, if made by the patient to the nurse, indicates that teaching about recognition and management of autonomic dysreflexia is successful? A. "I will perform self-catheterization at least six times per day." B. "A reflex erection may cause an unsafe drop in blood pressure." C. "If I develop a severe headache, I will lie down for 15 to 20 minutes." D. "I can avoid this problem by taking medications to prevent leg spasms."

a Autonomic dysreflexia is usually caused by a distended bladder. Performing self-catheterization five or six times a day prevents bladder distention. Signs and symptoms of autonomic dysreflexia include a severe headache. Patients should raise the head of the bed to 45 to 90 degrees. This action helps to relieve hypertension (systolic pressure up to 300 mm Hg) that occurs with autonomic dysreflexia.

A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? a. "It is really still too soon to know if you will have a return of function." b. "That could be a really positive finding. Can you show me the movement?" c. "That's wonderful. We will start exercising your legs more frequently now." d. "I'm sorry but the movement is only a reflex and does not indicate normal function."

b. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function; however, with the resolution of edema, some normal function may also occur. It is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function.

Priority Decision: The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. Respiratory diaphragmatic breathing b. Loss of all respiratory muscle function c. Decreased response of the sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention

a. Spinal injury below C4 will result in diaphragmatic breathing and usually hypoventilation from decreased vital capacity and tidal volume from intercostal muscle impairment. The nurse's priority actions will be to monitor rate, rhythm, depth, and effort of breathing to observe for changes from the baseline and identify the need for ventilation assistance. Loss of all respiratory muscle function occurs above C4 and the patient requires mechanical ventilation to survive. Although the decreased sympathetic nervous system response (from injuries above T6) and GI hypomotility (paralytic ileus and gastric distention) will occur (with injuries above T5), they are not the patient's initial priority needs

A 70-year-old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. Paraplegia with a flaccid paralysis b. Tetraplegia with total sensory loss c. Total hemiplegia with sensory and motor loss d. Spastic tetraplegia with loss of pressure sensation

b. At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.

A patient with paraplegia has developed an irritable bladder with reflex emptying. What will be most helpful for the nurse to teach the patient? a. Hygiene care for an indwelling urinary catheter b. How to perform intermittent self-catheterization c. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination

b. Intermittent self-catheterization five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur.

A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs

b. Neurogenic shock associated with cord injuries above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor and sensory losses are expected.

Two days following a spinal cord injury, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse? a. "You will have more normal function when spinal shock resolves and the reflex arc returns." b. "The extent of your injury cannot be determined until the secondary injury to the cord is resolved." c. "When your condition is more stable, MRI will be done to reveal the extent of the cord damage." d. "Because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete effect will be."

b. Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock and the reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation.

A 22-year-old female with paraplegia after a spinal cord injury tells the home care nurse that bowel incontinence occurs two or three times each day. Which action by the nurse is most appropriate? a. Take magnesium citrate (Citroma) every morning with breakfast. b. Teach the patient to gradually increase intake of high-fiber foods. c. Assess bowel movements for frequency, consistency, and volume. d. Instruct the patient to avoid all caffeinated and carbonated beverages

c The nurse should establish baseline bowel function and explore the patient's current knowledge of an appropriate bowel management program after spinal cord injury. To prevent constipation, caffeine intake should be limited, but not eliminated. Oral saline laxatives such as magnesium citrate are not indicated for long-term management of bowel elimination. Instruction on high-fiber foods is indicated if the patient has a knowledge deficit.

Priority Decision: During assessment of a patient with a spinal cord injury, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? a. Institute frequent turning and repositioning. b. Use tracheal suctioning to remove secretions. c. Assess lung sounds and respiratory rate and depth. d. Prepare the patient for endotracheal intubation and mechanical ventilation.

c. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient's breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help to mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gases (ABGs) deteriorate.

The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes

c. With the injury at T4, the highest-level realistic goal for this patient is to be able to be independent in self-care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable but it is not the highest-level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury. (See Table 61-4.)

Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury should the nurse expect to be used? a. Kinetic beds b. Hard cervical collar c. Skeletal traction with skull tongs d. Sternal-occipital-mandibular immobilizer brace

c. The development of better surgical stabilization has made surgery the more frequent treatment of cervical injuries. However, when surgery cannot be done, skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs is required to immobilize the cervical vertebrae, even if a fracture has not occurred. Hard cervical collars or a sternal-occipitalmandibular immobilizer brace may be used after cervical stabilization surgery or for minor injuries or stabilization during emergency transport of the patient. Sandbags may also be used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction.

What causes an initial incomplete spinal cord injury to result in complete cord damage? a. Edematous compression of the cord above the level of the injury b. Continued trauma to the cord resulting from damage to stabilizing ligaments c. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury

c. The primary injury of the spinal cord rarely affects the entire cord but the pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may compress the spinal cord as well as increase the damage as it extends above and below the injury site.

What is one indication for early surgical therapy of the patient with a spinal cord injury? a. There is incomplete cord lesion involvement. b. The ligaments that support the spine are torn. c. A high cervical injury causes loss of respiratory function. d. Evidence of continued compression of the cord is apparent.

d. Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.

Following a T2 spinal cord injury, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need? a. IV fluids b. Tube feedings c. Parenteral nutrition d. Nasogastric suctioning

d. During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur and nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who have difficulty swallowing and not until peristalsis returns. Parenteral nutrition would be used only if the paralytic ileus was unusually prolonged.