Exam 3: Spinal Cord Injury NCLEX Questions
c
A 22-yr-old woman with paraplegia after a spinal cord injury tells the home care nurse she experiences bowel incontinence two or three times each day. Which action by the nurse is most appropriate? a. Insert a rectal stimulant suppository. b. Teach the patient to gradually increase intake of high-fiber foods. c. Assess bowel movements for frequency, consistency, and volume. d. Instruct the patient to avoid all caffeinated and carbonated beverages.
c
A 25-yr-old male patient who is a professional motocross racer has anterior spinal cord syndrome at T10. His history is significant for tobacco, alcohol, and marijuana use. What is the nurse's priority when planning for rehabilitation? a. Prevent urinary tract infection. b. Monitor the patient every 15 minutes. c. Encourage him to verbalize his feelings. d. Teach him about using the gastrocolic reflex.
a
A patient who sustained a spinal cord injury a week ago becomes angry, telling the nurse I want to be transferred to a hospital where the nurses know what they are doing! Which reaction by the nurse is best? a. Ask for the patients input into the plan for care. b. Clarify that abusive behavior will not be tolerated. c. Reassure the patient about the competence of the nursing staff. d. Continue to perform care without responding to the patients comments.
c
A patient with SCI has spinal shock. The nurse plans care for the patient based on what knowledge? a. rehabilitation measures cannot be initiated until spinal shock has resolved b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia c. resolution of spinal shock is manifested by spasticity, reflex return, and neurogenic bladder d. patient will have complete loss of motor and sensory functions below the level of the injury, but autonomic functions are not affected
c
A patient with a C7 SCI undergoing rehabilitation tells the nurse he must have the flu because he has a bad headache and nausea. The nurse's first priority is to a. call the HCP b. check the patient's temperature c. take the patient's blood pressure d. elevate the HOB to 90 degrees
b
A patient with a T1 spinal cord injury is admitted to the intensive care unit. The nurse will teach the patient and family that a. use of the shoulders will be preserved. b. full function of the patients arms will be retained. c. total loss of respiratory function may occur temporarily. d. elevations in heart rate are common with this type of injury.
b
A patient with a T4 spinal cord injury experiences neurogenic shock as a result of SNS dysfunction. What would the nurse recognize as characteristic of this condition? a. Tachycardia b. Hypotension c. Increased urine output d. Peripheral vasoconstriction
c
A patient with a history of a T2 spinal cord injury tells the nurse, I feel awful today. My head is throbbing, and I feel sick to my stomach. Which action should the nurse take first? a. Assess for a fecal impaction. b. Give the prescribed antiemetic. c. Check the blood pressure (BP). d. Notify the health care provider.
a
A patient with a neck fracture at the C5 level is admitted to the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock on finding a. hypotension, bradycardia, and warm extremities. b. involuntary, spastic movements of the arms and legs. c. hyperactive reflex activity below the level of the injury. d. lack of movement or sensation below the level of the injury.
b
A patient with paraplegia has developed an irritable bladder with reflux emptying. Along with possible use of medications, what will be most helpful for the nurse to teach the patient? a. hygiene care for an indwelling urinary catheter b. how to perform intermittent self-catheterization c. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns d. that a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination
b
A patient with paraplegia resulting from a T10 spinal cord injury has a neurogenic reflex bladder. Which action will the nurse include in the plan of care? a. Educate on the use of the Cred method. b. Teach the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
c
A patient with spinal cord injury is experiencing severe neurologic deficits. What is the most likely mechanism of injury for this patient? a. compression b. hyperextension c. flexion-rotation d. extension-rotation
b
A week following SCI at T2, a patient experiences movement in his legs and tells the nurse that he is recovering some function. What is the nurse's best response? a. "it is really still too soon to know if you will have a return of function" b. "that could be a really positive finding. Can you show me the movement?" c. "that's wonderful. We will start exercising your legs more frequently now" d. "I'm sorry but the movement is only a reflex and does not indicate normal function"
b
In counseling patients with SCI regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion? a. he may have uncontrolled reflex erections, but orgasm and ejaculation are usually not possible b. he is most likely to have reflex erections and may experience orgasm if S2-S4 nerve pathways are intact c. he has a lesion with the greatest possibility of successful pyschogenic erection with ejaculation and orgasm d. he will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm
b
The nurse is caring for a patient admitted with a spinal cord injury after a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Séquard syndrome
a
The nurse is caring for a patient with a halo vest after cervical spine injury. Which care instructions should the nurse include in the patient's discharge plan? a. Keep a wrench close or attached to the vest. b. Use the frame and vest to assist in positioning. c. Clean around the pins using betadine swab sticks. d. Loosen both sides of the vest to provide skin care
d
The HCP has prescribed IV norepinephrine for the patient in the ED with SCI. The nurse determines that the drug is having the desired effect when what is observed in patient assessment? a. HR of 68 bpm b. respiratory rate of 24 c. temperature of 96.8 d. BP 106/82
c
The nurse is evaluating the neurologic signs of a client in spinal shock following SCI. Which observation indicates that spinal shock persists? a. hyperreflexia b. positive reflexes c. flaccid paralysis d. reflex emptying of the bladder
a b d e
The nurse is helping a client with a spinal cord injury to establish a bladder retraining program. Which strategies may stimulate the client to void? Select all that apply. a. Stroking the client's inner thigh b. Pulling on the client's pubic hair c. Initiating intermittent straight catheterization d. Pouring warm water over the client's perineum e. Tapping the bladder to stimulate the detrusor muscle f. Reminding the client to void in a urinal every hour while awake
a
The nurse performs discharge teaching for a 34-yr-old male patient with a thoracic spinal cord injury (T2) from a construction accident. Which patient statement indicates teaching about autonomic dysreflexia is successful? a. "I will perform self-catheterization at least six times per day." b. "A reflex erection may cause an unsafe drop in blood pressure." c. "If I develop a severe headache, I will lie down for 15 to 20 minutes." d. "I can avoid this problem by taking medications to prevent leg spasms."
c
When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak cough effort and loose-sounding secretions, the initial intervention by the nurse should be to a. suction the patients oral and pharyngeal airway. b. administer oxygen at 7 to 9 L/min with a face mask. c. place the hands on the epigastric area and push upward when the patient coughs. d. encourage the patient to use an incentive spirometer every 2 hours during the day.
a
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord injury, which nursing action has the highest priority? a. Assessment of respiratory rate and depth b. Continuous cardiac monitoring for bradycardia c. Application of pneumatic compression devices to both legs d. Administration of methylprednisolone (Solu-Medrol) infusion
d
When planning care for a patient with a cervical spinal cord injury (C5), which nursing diagnosis has the highest priority? a. Impaired urinary elimination related to tetraplegia b. Risk for impaired tissue integrity related to paralysis c. Disabled family coping related to the extent of trauma d. Ineffective airway clearance related to cervical spinal cord injury
d
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury, an appropriate patient goal is that the patient will be able to a. transfer independently to a wheelchair. b. drive a car with powered hand controls. c. turn and reposition independently when in bed. d. push a manual wheelchair on flat, smooth surfaces.
a
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses
c
Which intervention should the nurse perform first in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Check for bowel impaction c. Elevate the head of the bed d. Administer intravenous hydralazine
a
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds
d
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia in order to prevent autonomic dysreflexia? a. Assist with selection of a high protein diet. b. Use quad coughing to assist cough effort. c. Discuss options for sexuality and fertility. d. Teach the purpose of a prescribed bowel program.
c
Before surgical stabilization, what method of immobilization for the patient with a cervical SCI should the nurse expect to be used? a. kinetic beds b. hard cervical collar c. skeletal traction with skull tongs d. sternal-occipital-mandibular immobilizer brace
d
What is one indication for early surgical therapy of the patient with SCI? a. there is incomplete cord lesion involvement b. the ligaments that support the spine are torn c. a high cervical causes loss of respiratory function d. evidence of continued compression of the cord is apparent
c
A 26-year-old patient with a T3 spinal cord injury asks the nurse about whether he will be able to be sexually active. Which initial response by the nurse is best? a. Reflex erections frequently occur, but orgasm may not be possible. b. Sildenafil (Viagra) is used by many patients with spinal cord injury. c. Multiple options are available to maintain sexuality after spinal cord injury. d. Penile injection, prostheses, or vacuum suction devices are possible options.
a
A 70 year old patient is admitted after falling from his roof. He has a spinal cord injury at the C7 level. What findings during the assessment identify the presence of spinal shock? a. paraplegia with a flaccid paralysis b. tetraplegia with total sensory loss c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure sensation
a b d
A client with a SCI is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of this occurrence? Select all that apply a. keeping the linens wrinkle-free under the client b. preventing unnecessary pressure on the lower limbs c. limiting bladder catheterization to once every 12 hours d. turning and repositioning the client at least every 2 hours e. ensuring that the client has a bowel movement at least once a week
b
A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should the nurse take first? a. Administer the ordered acetaminophen. b. Check the Foley tubing for kinks or obstruction. c. Adjust the temperature in the client's room. d. Notify the health care provider about the change in status.
d
A client with a spinal cord injury at level C3 to C4 is being cared for by the nurse in the emergency department (ED). What is the priority nursing assessment? a. Determine the level at which the client has intact sensation. b. Assess the level at which the client has retained mobility. c. Check blood pressure and pulse for signs of spinal shock. d. Monitor respiratory effort and oxygen saturation level.
a
A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? a. condom catheter b. intermittent urinary catheterization c. Crede's method d. indwelling urinary catheter
d
A nurse is caring for a client who experiences a cervical spine injury 24 hours ago. Which of the following prescriptions should the nurse clarify with the provider? a. anticoagulant b. plasma expanders c. H2 antagonists d. muscle relaxants
d
A nurse is caring for a client who has a C4 SCI. The nurse should recognize the client is at greatest risk for which of the following complications? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise
b
A nurse is caring for a client who has a SCI who reports severe headache and is sweating profusely. Vital signs include BP 220/110 and apical HR of 54. Which of the following actions should the nurse take first? a. examine the skin for irritation or pressure b. sit the client upright in bed c. check the urinary catheter for blockage d. administer antihypertensive medication
a
A nurse is planning care for a client who has a SCI involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurse's highest priority? a. prevention of further damage to the spinal cord b. prevention of contractures of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair
b
A patient is admitted to the ED with SCI at the level of T2. Which clinical finding is of most concern by the nurse? a. SpO2 of 92% b. heart rate of 42 bpm c. BP of 88/60 d. loss of motor and sensory function in the arms and legs
a
A patient is admitted to the ED with a possible cervical SCI following an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. maintaining a patent airway b. assessing the patient for head and other injuries c. maintaining immobilization of the cervical spine d. assessing the patient's motor and sensory function
c
After a 25-year-old patient has returned home following rehabilitation for a spinal cord injury, the home care nurse notes that the spouse is performing many of the activities that the patient had been managing during rehabilitation. The most appropriate action by the nurse at this time is to a. tell the spouse that the patient can perform activities independently. b. remind the patient about the importance of independence in daily activities. c. develop a plan to increase the patients independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patients care and support the spouses participation.
c
During assessment of the patient with SCI, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? a. institute frequent turning and repositioning b. use tracheal suctioning to remove secretions c. assess lung sounds and respiratory rate and depth d. prepare the patient for ET intubation and mechanical ventilation
a
During rehabilitation, a patient with spinal cord injury begins to ambulate with long leg braces. Which level of injury does the nurse associate with this degree of recovery? a. L1-2 b. T6-7 c. T1-2 d. C7-8
a
During the patient's process of grieving for the losses resulting from SCI, what should the nurse do? a. help the patient to understand that working through the grief will be a lifelong process b. assist the patient to move through all stages of the mourning and grief process to acceptance c. let the patient know that anger directed at the staff or the family is not a positive coping mechanism d. facilitate the grieving process so that it is completed by the time the patient is discharged from rehabilitation
d
Following a T2 SCI, the patient develops paralytic ileus. While this condition is present, what should the nurse anticipate that the patient will need? a. IV fluids b. tube feedings c. parenteral nutrition d. nasogastric suctioning
a
How is urinary function maintained during the acute phase of SCI? a. an indwelling catheter b. intermittent catheterization c. insertion of a suprapubic catheter d. use of incontinent pads to protect the skin
a c d e
When caring for a patient who experienced a T1 spinal cord transsection 2 days ago, which collaborative and nursing actions will the nurse include in the plan of care? Select all that apply a. Urinary catheter care b. Nasogastric (NG) tube feeding c. Continuous cardiac monitoring d. Avoidance of cool room temperature e. Administration of H2 receptor blockers
a
The patient was in a traffic collision and is experiencing loss of function below C4. Which effect must the nurse be aware of to provide priority care for the patient? a. respiratory diaphragmatic breathing b. loss of all respiratory muscle function c. decreased response of the SNS d. GI hypomobility with paralytic ileus and gastric distention
b
Two days following SCI, a patient asks continually about the extent of impairment that will result from the injury. What is the best response by the nurse? a. "you will have more normal function when spinal shock resolves and the reflux arc returns" b. "the extent of your injury cannot be determined until the secondary injury to the cord is resolved" c. "when your condition is more stable, MRI will be done to reveal the extent of the cord damage" d. "because long-term rehabilitation can affect the return of function, it will be years before we can tell what the complete affect will be"
c
What causes an initial SCI to result in complete cord damage? a. edematous compression of the cord above the level of injury b. continued trauma to the cord resulting from damage to stabilizing ligaments c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites d. mechanical transection of the cord by sharp vertebral bone fragments after the initial injury