Spinal Cord Prep U

For a patient with and 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 spinal cord injury has full head and neck control when the injury is at which level?

C5

A 24-year old female rock climber is brought to the ED after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the brain is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid With fractures at the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

A client sustained a TBI. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling catheter

A client who has experienced a spinal cord injury still has use of the arms but has impaired motor and sensory function in the trunk, legs, and pelvic organs. Which term best describes how this injury is classified?

Paraplegia

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in the client's care plan?

Risk for injury

While teaching a class of nursing students about spinal cord injury, the instructor mentions that male SCI clients will be able to have a sexual response if their injury is at which level on the spinal cord?

S4

Autonomic dysreflexia can occur with spinal cord injuries above which of the following?

T6

The earliest sign of serious impairment of brain circulation related to ICP is:

a change in consciousness

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 at T8 would likely retain normal motor and somatosensory function of her:

arms

A client with a T-4 level SCI is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

autonomic dysreflexia

The nurse is caring for a patient in the ED with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

burr holes An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temp control. Which would not be an expected outcome of care?

client maintains mechanical ventilation with minimal mucus accumulation a client with lumbar spinal injury would not require mechanical ventilation

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measure's the client's temperature every 15 minutes. This measurement is important to:

decrease the potential for brain damage

After a spinal cord injury at S2-S4, most people experience constipation. Why does this occur?

defecation reflex is lost

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order:

famotidine

The nurse is discussing spinal cord injury at the health fair at a local high school. The nurse relays that the most common cause of SCI is:

motor vehicle crashes

What are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

The nurse in the ED is caring for a patient brought in by the rescue squad after falling from a second story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar fracture

The nurse is caring for a client with a spinal cord injury. Assessment reveals shallow breath sounds and a weak cough effort. The nurse correlates this with which level of injury on the spinal column?

C5

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?

assess for a halo sign

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temperature

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?

establishing an intermittent catherization routine every 4 hours

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client:

vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately.

A nurse is caring for a 16-year old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

she'll have to apply restraints to prevent the client from dislodging the endotracheal tube (ET)

Which complication of spinal cord injury is the most preventable in a paraplegic client?

skin breakdown

You are a neurotrauma nurse working in the neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?

observe for any signs of behavioral changes

A client has sustained an acute spinal cord injury in a fall from a tree stand during a hunting trip. The client will require surgical intervention for the unstable spinal cord. What does the nurse recognize is the goal of early surgical intervention for this client?

provide internal skeletal stabilization

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a results of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

raise the head of the bed and place the patient in a sitting position

A client with a T-4 level SCI is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

rebound hypotension

The nurse received a report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

the client has cerebral spinal fluid leaking from the ear

The nurse is admitting a client from the ED with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

traction with weights and pulleys

The nurse reviews the physician's ED progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area. A subdural hematoma is a collection of blood between the dura and the brain, as space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

Several months ago, a 20 year old male suffered a spinal cord injury brought about by a snowboard trick gone wrong. The lasting effects of his injury include flaccid bowel and bladder and the inability to obtain an erection. While sensation has been completely preserved in his legs and feet, his motor function is significantly impaired. What type of incomplete spinal cord injury has the man most likely experienced?

Conus medullaris syndrome Functional deficits resulting from conus medullaris syndrome usually result in flaccid bowel and bladder and altered sexual function. Sacral segments occasionally show preserved reflexes if only the conus is affected. Motor function in the legs and feet may be impaired without significant sensory impairment. Anterior cord syndrome and Brown-Sequard syndrome include a loss of pain and temp sensation while central cord syndrome manifests in spastic paralysis and is more common among older adults.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the clients family?

Look for signs of increased intracranial pressure

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of the client care?

Monitoring is needed as rapid neurologic deterioration may occur

A neurologic nurse is explaining the structure and function of motor units to a client who has a spinal cord injury. The nurse should describe which components of a motor unit?

Neuromuscular junction Skeletal muscle Lower motor neuron

A client presents to the ED stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Parasthesia When a client reports numbness and tingling in an area, he is reporting paresthesia. The nurse would document the experience as such or place the client's word in parentheses.

The nurse is caring for a client immediately following a spinal cord injury. Which is an acute complication of SCI?

Spinal shock Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis. The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

The nurse is caring for a client with TBI. Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temp increase from 98.0 F to 99.6 F

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

Acute

A client who has experienced a SCI has an ipsilateral loss of voluntary motor function and a contralateral loss of pain and temperature sensation. Based on these symptoms, which classification of spinal cord injury does the client have?

Brown Sequard Brown Sequard syndrome results from damage to a hemisection of the anterior and posterior cord. The effect is an ipsilateral loss of voluntary motor function from the corticospinal tract and proprioception loss with a contralateral loss of pain and temperature sensation from the lateral spinothalamic tracts for all levels below the lesion.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of a UTI. Which symptom is an early sign of UTI in a client with SPI?

fever and change in clarity

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolic stockings prior to elevation of the head

What is the most common cause of spinal cord injury?

Motor vehicle crashes