Spinal cord injury , autonomic dysreflexia

. A nurse is caring for a client with a thoracic spinal cord injury. As part of the nursing care plan, the nurse monitors for spinal shock. In the event that the spinal shock occurs, the nurse anticipates that the most likely IV fluid to be prescribe would be:

- 0.9% Normal Saline

The HCP orders administration of IV methylprednisolone for the first 24 hrs to a client who experienced a SCI 3 hrs ago. The nurse explains to the client that this drug

- Reduces Spinal Cord Edema and improves nerve impulse conduction

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the patient's BP. C. Place the patient in the Trendelenberg position. D. Prepare an ice bath to lower core body temperature.

. Prepare for interventions to increase the patient's BP.

70. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities

A. Absence of reflexes along with flaccid extremities

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first? A. Check the patient's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion. C. Administer analgesia. D. Reassure the patient that headaches are expected after spinal cord injuries

A. Check the patient's indwelling urinary catheter for kinks to ensure patency.

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

A. Hyperthermia

1. A patient 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 patient? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP

A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT

78. A client with spinal cord injury is experiencing autonomic hyperreflexia. The nurse should carefully monitor this client for which manifestations? SATA (Reviews and rationales) A. Severe, throbbing headache B. Warm, moist skin of the head and neck C. Hypertension D. Tachycardia E. Hot sweaty skin below level of injury

A. Severe, throbbing headache B. Warm, moist skin of the head and neck C. Hypertension

81. The assessment priority of a client with SCI is -

Airway and respiratory status

The nurse expects ___ syndrome when a client with spinal cord trauma has loss of motor function and temperature sensation below the level of the lesion while light touch, position, and vibration remain intact? -

Anterior cord

A nurse is caring for a client who has had a complete cervical spine injury for many years. The client tells the nurse he has an extreme headache. The nurse assesses a blood pressure of 190/100. Which of the following interventions should be performed first? -

Assess for kinked foley catheter and or bowel impaction

Patient comes in (suspected autonomic dysreflexia), what do you do first -

Assess the bladder

66. A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? A. Placing the patient on a fluid restriction as ordered B. Applying thigh-high elastic stockings C. Administering an antifibrinolyic agent D. Assisting the patient with passive range of motion (PROM) exercises

B. Applying thigh-high elastic stockings

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertension C. Tachycardia and agitation D. Third-spacing and hyperthermia

B. Bradycardia and hypertension

77. A client is admitted to the emergency department following a motor vehicle crash. While completing a neurological aassessment, the client pulls his arms inward and upward while the nurse is eliciting a pain response. The nurse identifies that the positioning is significant for which of the following? Select all that apply (Reviews and rationales) A. Decerebrate posturing B. Decorticate posturing C. Injury to the brain stem D. Injury to the pons E. Injury to the midbrain

B. Decorticate posturing E. Injury to the midbrain

A client experienced a spinal cord injury at the level of T5 rings the call bell for assistance. Upon entering the room, the client finds to have flushed head and neck, is diaphoretic, and reports severe headache. The clients pulse is 47, the BP is 220/114 mmHg. The nurse concludes that the client needs immediate treatment for which condition? (Reviews and rationales) A. Malignant hypertension B. Pulmonary embolism C. Autonomic hyperreflexia D. Spinal shock

C. Autonomic hyperreflexia

The nurse reads in an admission note that the physical examination of a client revealed impairment of cranial nerve number II. The nurse gives ancillary caregivers which instructions when caring for this client? Select all that apply A. Whisper to the client B. Serve food at room temperature C. Clear the clients path of obstacles D. Report difficulty swallowing E. Ensure adequate lighting for tasks

C. Clear the clients path of obstacles E. Ensure adequate lighting for tasks

A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

C. Ineffective breathing patterns related to weakness of the intercostal muscles

7. A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action? A. Repositioning the patient every 2 hours B. Initiating range-of-motion exercises (ROM) as soon as the patient initiates C. Initiating (ROM) exercises as soon as possible after the injury D. Performing ROM exercises once a day

C. Initiating (ROM) exercises as soon as possible after the injury

The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the patient in a high Fowler's position when in bed. B. Support the knees with a pillow when the patient is in bed. C. Perform passive ROM exercises as ordered. D. Administer NSAIDs as ordered.

C. Perform passive ROM exercises as ordered.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient 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? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia

C. Spinal shock

4. The nurse on the rehab unit is caring for the following clients. Which client should the nurse assess first after receiving the change of shift report? -

C6 spinal cord who is complaining of dyspnea and has crackles in his lungs

. Which mobility goal can the nurse expect for the client diagnosed with spinal cord injury at the level of L5? (KAPLAN) A. Wheelchair bound but independent B. Limited ambulation with bilateral long braces C. Ambulation with short leg braces D. Independent ambulation without equipment

D. Independent ambulation without equipment

. 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? A. Sports-related injuries B. Acts of violence C. Injuries due to a fall D. Motor vehicle accidents

D. Motor vehicle accidents

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider? A. The patient will be unable to use a wheelchair. B. The patient will be unable to swallow food. C. The patient will be continent of urine, but incontinent of bowel. D. The patient will require full assistance for all aspects of elimination.

D. The patient will require full assistance for all aspects of elimination.

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patient's current health status is most likely to have precipitated this event? A. The patient received a blood transfusion. B. The patient's analgesia regimen was recent changed. C. The patient was not repositioned during the night shift. D. The patient's urinary catheter became occluded.

D. The patient's urinary catheter became occluded.

. Patient on solumedrol -

Decrease edema

9. A client with a cervical neck fracture at the C5 level is admitted to the ICU following initial treatment in the ER. During initial assessment of the client, the nurse recognizes the presence of spinal shock upon finding? -

Flaccid paralysis and lack of sensation below the level of injury

Client with massive trauma and possible SCI is admitted to the ED. Nurse suspects that the client may be experiencing neurogenic shock in addition to hypovolemic shock, based on the finding of: -

HR of 58 BPM (Bradycardia)

A nurse in the ER assesses a client who was injured in a driving accident 2 hours earlier. A ct scan reveals a fracture of the C4 cervical vertebra. The client is breathing independently but has no movement or muscle tone from below the area of injury. The nurse understands that the client? -

Has Spinal shock

Neurogenic bladder. Initial treatment for autonomic dysreflexia? -

Intermittent catheterization every 4 hours

A patient in shock, how are you going to assess that there is adequate tissues perfusion: -

Look at LOC, urine output, skin color, and look at BP.

0. A client is brought to the ER following an MVA. Priority intervention for client with a suspected cervical spine injury is -

Maintain alignment of the head and neck

82. A client with a spinal cord injury at C3-4 is being cared for in the ER. What is the priority assessment? -

Monitor respiratory effort and oxygen saturation level

Bowel and bladder function are impaired after a complete spinal cord injury. Which of the following statements about what occurs immediately after the injury is true? -

NG tube usually inserted to decompress the stomach

Spinal shock vs neurogenic shock: -

Neurogenic shock everything will be low (bradycardia, hypotensive, pale warm skin

A client diagnosed with C4 cervical spine injury is treated for respiratory insufficiency. Which of these manifestations would indicate that the client's condition is worsening? SATA -

Reduce chest excursion, pco2 of 55, and poor cough effort

What do steroids do in spinal shock -

Reduces spinal edema

Initial x-ray and MRI result indicate that a client has an incomplete spinal cord lesion at C8. During the first 72 hours after injury the nurse plans care for the client with knowledge that the complete cord damage will result from -

Secondary injury to the cord

. Spinal shock initial treatment -

Solumedrol

Spinal cord compression S&S -

Sudden onset of back pain

The new graduate nurse is administering 0800 medications to a client with a recent SCI and hx of diabetes. Which action by the new grad. Warrants immediate intervention by the charge nurse?

The new grad - Administers the sliding scale of humilin R via IV push

If you have a patient that all of a sudden become hypotensive, the first thing to assess is: -

Urine output and we need to give fluids to resuscitate patient before we start any drugs

A client is admitted with a spinal cord injury and high dose methyl prednisone therapy is initiated. Which of these lab results would require immediate follow up by the nurse? -

WBC of 20,000

83. C4 injury -

Want to protect and assess airway