Unit V: Spinal Questions and notes

When assessing the client with a cord transection above T5 for possible complications, which complication is least likely to occur? 1. diarrhea 2. paralytic ileus 3. stress ulcers 4. intra-abdominal bleeding

1 ( 1. The client with a spinal cord transection above T5 is least likely to develop diarrhea. Rather, constipation due to atonia would be possible. The client with a spinal cord transection above T5 is at risk for development of a paralytic ileus because the sympathetic nerve innervation to the vagus nerve, which dominates all the vessels and organs below T5 (e.g., the intestinal tract), has been disrupted and, therefore, so has movement or peristalsis. The client is at risk for development of stress ulcers because the sympathetic nerve innervation to the stomach has been disrupted, which results in an excessive release of hydrochloric acid in the stomach, allowing contact of hydrochloric acid with the stomach mucosa. The client does not feel subjective signs of stress ulcers (e.g., pain, guarding, tenderness) and therefore is at increased risk for bleeding because complications of an ulcer can develop before early diagnosis.)

When the client has a cord transection at T4, the nurse should focus the assessment on: 1. renal status. 2. vascular status. 3. gastrointestinal function. 4. biliary function.

2 (Although assessment of renal status, gastrointestinal function, and biliary function is important, with the spinal cord transection at T4 the client's vascular status is the primary focus of the nursing assessment because the sympathetic feedback system is lost and the client is at risk for hypotension and bradycardia)

Which is the best method to assess for the development of deep vein thrombosis in a client with a spinal cord injury? 1. Homans' sign 2. pain 3. tenderness 4. leg girth

4 ( Measuring the leg girth is the most appropriate method because the usual signs, such as a positive Homans' sign, pain, and tenderness, are not present. Other means of assessing for deep vein thrombosis in a client with a spinal cord injury are through a Doppler examination and impedance plethysmography.)

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 accurate. 1. "These movements indicate that the damaged nerves are healing." 2. "This is a good sign. Keep trying to move all the affected muscles." 3. "The return of movement means that eventually you should be able to walk again." 4. "The movements occur from muscle reflexes that cannot be initiated or controlled by the brain."

4 ( The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control.)

shoulders

Assessment with spinal cord injury to C4 and C5 Check the _______

arm pulling up from resistance

Assessment with spinal cord injury to C5-C6

arm straightening

Assessment with spinal cord injury to C7

hands

Assessment with spinal cord injury to C8 Check the ______

T6

Autonomic dysreflexia is overstimulation of the sympathetic nervous system that cannot be resolved by the parasympathetic system due to a blockage in the spinal cord from an injury at or above _____.

note

Exaggerated spasticity, muscle rigidity, and tinnitus are adverse effects of baclofen (Lioresal) that the nurse should discuss with the HCP. Baclofen Answer: note

vascular status (bradycardia, hypotension)

Important assessment with T4 injury

blurred vision, headache, diaphoresis, hypertension, bradycardia

S/S of autonomic dysreflexia

2 (The client is experiencing spinal shock that manifests within a few hours after the injury. Hypotension, flaccid paralysis, and absence of muscle contractions occur. Spinal shock lasts 7 to 20 days, and the SCI cannot be classified accurately until spinal shock resolves.)

The nurse assesses the client, who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem? 1. Complete spinal cord transection 2. Spinal shock 3. An upper motor neuron injury 4. Quadriplegia

1 2 4 5 (1. Blurred vision results from the hypertension occurring with autonomic dysreflexia. 2. Hypertension is a symptom of autonomic dysreflexia from overstimulation of the sympathetic nervous system (SNS). 3. Bradycardia (not tachycardia) results from autonomic dysreflexia; the parasympathetic nervous system attempts to maintain homeostasis by slowing down the HR. 4. Headache results from the hypertension occurring with autonomic dysreflexia. 5. Sweating results from the sympathetic stimulation above the level of injury. ➧ Test-taking Tip: Autonomic dysreflexia is overstimulation.)

The nurse is caring for the client with an SCI at the level of the sixth cervical vertebra. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply. 1. Blurred vision 2. BP 198/102 mm Hg 3. Heart rate 150 bpm 3. Extreme headache 4. Sweaty face and arms