SCI

Which cranial nerve is responsible for the autonomic dysreflexia? A. Vagus B. Abducens C. Vestibulocochlear D. Trigeminal

A.

A 22-year-old patient has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. Twenty-four hours after the injury, the patient tells the nurse, This will be good for me. I can handle this and I'm doing fine. Which response from the nurse is most likely indicated? A. Ask the patient if he would like to speak with a spiritual advisor or social worker B. Continue to treat the patient as is but remind him that he may never walk again C. Make arrangements for the patient to be discharged to home. D. Ask the physician to discontinue pain medications, since it is clear the patient does not need them

A. Ask the patient if he would like to speak with a spiritual advisor or social worker Rational: The patient in the situation described may most likely be suffering from denial as an initial response after his injury. Not all people who are injured and who develop paraplegia will react the same way, but many people who are injured in this method develop anxiety and depression and may have difficulties coping with the outcome of the situation. Some patients develop denial initially after the injury, which often resolves after several months. In this case, the nurse may want to offer a resource such as a social worker or spiritual advisor.

The client has a spinal cord injury and is suffering from spinal shock. What is a symptom you might expect? A. Bradycardia B. Spacsticity C. Increased visceral reflexes D. Hypertension

A. Bradycardia A client with spinal shock is expected to be hypotensive, have bradycardia, decreased visceral reflexes and flaccid paralysis of skeletal muscles.

A nurse has gathered an interdisciplinary team to work together to coordinate care for a patient with a spinal cord injury. Which best describes the nurse's role in collaborating with other members of the team to provide care for this patient? A. Informing the team members about the status of the client's health B. Contacting the client and telling him the team will have a meeting C. Documenting in the patients chart that the team meeting will take place D. Being a source of professional guidance when a team member needs information about therapy

A. Informing the team members about the status of the client's health Rational: The members of the interdisciplinary team may often gather to discuss a patients condition and to make plans for his care. The nurse often acts as a team coordinator by ensuring that appropriate disciplines are present and by updating the members of the team about the patients status. Because the nurse is the most likely person who will provide direct care for the patient on a regular basis, the nurse is the one who can update the team about the patients progress.

What is the most common cause of spinal cord injuries? A. MVAs B. Horseback riding C. Swimming D. Running

A. MVAs Silvestri 902 The most common causes of SCIs include MVAs, falls, sporting, industrial accidents, gunshot, and stab wounds.

The nursing care plan of a client with spinal cord injury should include what? Select all that apply. A. Maintain stable vital signs. B. Provide skeletal traction. C. Avoid steroid therapy. D. Prepare client for surgical stabilization of spine. E. Administer antispasmodics.

A. Maintain stable vital signs, B. Provide skeletal traction, D. Prepare client for surgical stabilization of spine. E. Administer antispasmodics.

Which of the following factors increase the risk of spinal cord injury? Select all that apply. A. Male gender B. Female gender C. African American or Asian ethnicity D. Age between 16-30 E. Age between 55-80 F. Underlying arthritis

A. Male gender, D. Age between 16-30 , F. Underlying arthritis Rational: Spinal cord injury occurs with damage to an area of the spinal cord and outlying nerves; significant injury often causes loss of sensation and function in parts of the body below the area of injury. Spinal cord injury can occur from a traumatic event or through a disease process that affects the bones and joints. Men and teen boys between the ages of 16 and 30 years are at higher risk of incurring a traumatic spinal cord injury. The presence of certain bone or joint diseases, such as osteoporosis or arthritis can also increase the risk of this type of injury.

Sympathetic (fight or flight) is located in what part of the spinal cord: A. T1-L2-L3 B. S2-S4 C. T4-T10 D. C1-C3

A. T1-L2-L3

A patient has suffered a spinal cord injury after a fall. When he is brought in for care, the patient experiences diaphoresis and headache; the nurse notes that his blood pressure is 148/102 mmHg. Which response should the nurse perform first? A. Ask the patient to perform the Valsalva maneuver B. Raise the head of the bed, lower the legs, and remove constrictive clothing C. Straight cath the client D. Administer antihypertensive medication and apply hemodynamic monitoring E. Assess the client for fecal impaction

B. Raise the head of the bed, lower the legs, and remove constrictive clothing Rational: A patient with a spinal cord injury is at risk for autonomic dysreflexia, which is characterized by sudden and severe hypertension as a result of noxious stimuli. The patient may develop the condition from various factors, including bladder distention or stool impaction. The nurse's first intervention is to raise the patients head, lower the legs, and loosen constrictive clothing, which could contribute to the condition.

Parasympathetic (rest and digest) is located in what part of the spinal cord: SATA A. T1-L2-L3 B. S2-S4 C. T4-T10 D. C1-C3 E. Brainstem D. Sacrum

B. S2-S4 E. Brainstem

A patient with a spinal cord injury has difficulty determining when he needs to empty his bladder. The nurse teaches him about tapping to stimulate voiding. How would the nurse describe tapping to this patient? A. The patient bears down to increase pressure and then taps the base of the abdomen with his hand to release urine B. The area over the bladder is tapped to stimulate the bladder muscles C. The patient wears a device that acts as a tap or faucet to stop and start urine flow D. The patient alternately taps the abdomen and the back to signal messages across the body to promote urination

B. The area over the bladder is tapped to stimulate the bladder muscles. Rational: A patient with a spinal cord injury may be unable to control urine flow if he has little to no sensation in the bladder that tells the brain when it is time to empty the bladder. The nurse may teach the patient about some techniques that can stimulate urine flow. Tapping involves lightly tapping the area over the bladder with the fingertips to stimulate detrusor muscle contractions.

Injury to the C2 vertebrae usually results in: A. full recovery with treatment B. death

B. death Silvestri p904 C2 to C3 injuries are usually fatal

The most appropriate prevention against spinal cord injury is what? A. avoid surfing B. use seat belts in the car C. avoid horseback riding without a helmet D. drink in moderation before driving

B. use seat belts in the car The most appropriate prevention against spinal cord injury is to use seatbelts in the car. There should be no drinking and driving whatsoever. Surfing and horseback riding are less likely causes of spinal cord injury.

Steps in order of treating autonomic dysreflexia A. treat HTN B. prevention C. Elevate head of bed D. Find and remove cause

C, D, A, B

What is the first step in treating autonomic dysreflexia? A. Provide oxygen B. Provide Nitroglycerin C. Elevate head of the bed D. Lower the head of the bed

C. Elevate the head of the bed

A patient has suffered a spinal cord injury after a diving accident. When first brought to the emergency room, the patient is suffering from spinal shock. Which symptoms best describe this condition? A. Hypotension, headache, and blurred vision B. Back pain, muscle spasms, and difficulty walking C. Decreased venous return and skin breakdown in the extremities D. Flaccid paralysis and anesthesia in the lower extremities

D. Flaccid paralysis and anesthesia in the lower extremities Rational: Following a spinal cord injury, a patient may develop spinal shock, which is a condition characterized by loss of neurological activity below the level of injury. The patient in spinal shock typically has no feeling or movement in the body below the level of injury. It differs from permanent spinal cord injury in that it is a temporary condition that may last up to 6 weeks after the initial injury and does not involve destruction of the spinal cord that leads to permanent effects.

S/sx of autonomic dysreflexia

HTN and bradycardia; pounding headache; flushed face; red blotches on skin above the level of injury; sweating above level of injury; nasal stuffiness; nausea; goose bumps; pale skin below level of injury; cold, clammy skin below injury Increased BP, flushing above injury, pallor below injury, 1st compliant is severe headache, bradycardia.

Medications to treat HTN with autonomic dysreflexia

Nitropaste, nifedipine (CCB), hydralazine IV (vasodilator)

Autonomic dysreflexia

Occurs with injuries above or at T6 after spinal shock has resolved

Causes of autonomic dysreflexia

Overstretched irritated bladder, constipation/impaction, pressure to skin from sitting, restrictive clothing, wrinkles in sheets

How can we treat decreased cough with SCI patients?

Quad cough manuever

Care immediately post injury ABCs

Respirations; decreased depth, decreased cough, loss of use of the diaphragm. Patient will have diminished breath sounds because the phrenic nerve is effected Cardiac: decreased influence of the sympathetic nervous system, decreased pulse, peripheral vasodilation, decreased blood pressure, postural hypotension

Tetraplegia

SCI at C8 and above

Paraplegia

SCI at T1 and below

Care immediately post injury

Urinary system: if shock loss of bladder tone, over-distention, retention