Spinal Cord Injury
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.
- young age - male - alcohol use
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?
Fever and change in urine clarity
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?
Flat, except for logrolling as needed
The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
Perform passive ROM exercises as prescribed.
The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?
Prepare for interventions to increase the client's BP.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?
Check the client's indwelling urinary catheter for kinks to ensure patency.
Which are characteristics of autonomic dysreflexia?
severe hypertension, slow heart rate, pounding headache, sweating
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
spasticity
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?
Ineffective breathing patterns related to weakness of the intercostal muscles
The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?
Insertion of a nasogastric tube
