SCI PrepU

severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family?

Autonomic dysreflexia

A client with a T4 level spinal cord injury (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?

Flat, except for logrolling as needed

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?

C5

At which spinal cord injury level does the patient have full head and neck control?

T6

Autonomic dysreflexia can occur with spinal cord injuries above which level?

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

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

Loss of sympathetic innervation causes a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked

Clinical manifestations of neurogenic shock include?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Meticulous cleanliness

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which nursing intervention will most protect the client against pressure ulcers?

Autonomic dysreflexia

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?

Traction with weights and pulleys

The nurse is admitting a client from the emergency department 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?

severe hypertension, slow heart rate, pounding headache, sweating

Which are characteristics of autonomic dysreflexia?

Fever and change in urine clarity

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?

They help prevent the development of contractures

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?

all reflexes are absent and the extremities are flaccid

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

Insertion of a nasogastric tube to relieve distention and to prevent vomiting and aspiration

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?

young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use

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

Motor vehicle crashes

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

Rebound hypotension

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?

Place in a seated position

A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first?

To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid)

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:

regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. What will the nurse encourage the caregiver to do?

decrease the potential for brain damage

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 measures the client's temperature every 15 minutes. This measurement is important to:

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

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?

Monitoring the patency of an indwelling urinary catheter

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

Respiratory arrest and spinal shock

Which of the following are the immediate complications of spinal cord injury?

Autonomic dysreflexia

You are a neurotrauma nurse working in a 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?

Place the patient in a sitting position to lower BP

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?

Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. 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 is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. What education should the nurse provide to the patient?