SCI

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.

Eating Breathing Transferring to a wheelchair Writing

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Suction the airway.

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

Establishing an intermittent catheterization routine every 4 hours

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except?

Being an athlete

The nurse is planning the care of a client 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?

Change the client's position frequently.

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

A client has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication would the nurse provide as ordered by the healthcare provider to decrease the blood pressure?

Hydralazine hydrochloride IV, administered slowly

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.

Hypotension Venous pooling Tachypnea Hypothermia

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation.

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension?

Monitor the client's BP before and during position changes.

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?

Motor vehicle accidents

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

Motor vehicle crashes

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurological exam

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client 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?

Spinal shock

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

Spinal shock

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

T6

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

increase the frequency of the catheterizations.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?

The first thoracic vertebrae

A nurse on a neurological unit is participating in the care of a female patient who is receiving treatment for a spinal cord injury (SCI) that she experienced 2 weeks ago. The patient's care plan specifies measures to prevent skin breakdown, and the nurse has planned several changes of position during the shift. How should the nurse best reposition this patient?

"Log roll" the patient.

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

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

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

A public health nurse is participating in a health promotion workshop and is teaching a group of high school students how to respond if a person suffers an apparent spinal cord injury. The nurse should instruct participants to:

Keep the victim's head in a neutral position at all times.

A public health nurse has formed a partnership with an advocacy group that acts on behalf of individuals who have experienced spinal cord injuries (SCIs). Health promotion efforts are being planned with a knowledge that the incidence of SCIs varies widely between demographic groups. What population has the highest incidence of spinal cord injuries?

Males between ages 16 and 30

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?

Oliguria and serum hyponatremia

A client 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 client? Select all that apply.

Orthostatic hypotension Autonomic dysreflexia DVT

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Placing a blanket over the client

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider?

The client will require full assistance for all aspects of elimination.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently.

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client?

They have the beginning of a pressure sore.

Which are possible long-term complications of spinal cord injury? Select all that apply.

autonomic dysreflexia respiratory infection

A client with a T4-level spinal cord injury (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

A 36-year-old male patient is preparing for discharge from the hospital to a rehabilitative facility 4 weeks after he suffered a spinal cord injury (SCI) during a workplace accident. The hospital nurse should be aware that the primary focus of this coming phase of the patient's recovery will be:

Providing him with the skills to perform as many activities of daily living (ADLs) as possible