Spinal Cord Injury-Critical Care

A client who sustained a cervical neck injury 2 days ago is demonstrating an irregular respiratory pattern with the rate of 8-10 breaths per minute. Based on this data, which is the priority nursing diagnosis? A) Impaired Physical Mobility B) Autonomic Dysreflexia C) Ineffective Breathing Pattern D) Impaired Gas Exchange

Answer: C Explanation: Since the client sustained the neck injury 2 days prior, the full extent of the injuries cannot yet be determined. The client's rate of respirations should be between 12 and 20 per minute. Since the client is breathing irregularly at a rate of 8-10 breaths per minute, the client may need assisted ventilation or a tracheostomy. The nursing diagnosis priority for this client would be Ineffective Breathing Pattern. An Impaired Gas Exchange could occur because of the Ineffective Breathing Pattern and would be the second in priority for this client. Impaired Physical Mobility and Autonomic Dysreflexia could be addressed at a later time.

The healthcare provider prescribes 2.5 mg IV of morphine sulfate to be administered to a patient with a ruptured intervertebral disk whose pain has not been controlled with NSAIDs and muscle relaxants. The nurse has a 1 milliliter (mL) syringe containing 10 mg of morphine sulfate. How many milliliters of morphine sulfate does the nurse need to withdraw from the syringe? _____ mL

Correct Answer: 0.25 Rationale: The nurse can use the equation Dosage Required/Dosage Available × 1 mL. For this situation the equation would be 2.5 mg/10 mg × 1 mL = 2.5/10 × 1 mL = 0.25 × 1 mL = 0.25 mL.

The healthcare provider prescribes 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5-milliliter (mL) ampule containing 60 mg of ketorolac. How many milliliters of ketorolac does the nurse need to withdraw from the syringe? _____ mL

Correct Answer: 1.25 Rationale: The nurse can use the equation Dosage Required/Dosage Available × 1 mL. For this situation the equation would be 15 mg/60 mg × 5 mL = 15/60 × 5 mL = 0.25 × 5 mL = 1.25 mL.

A nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Arrange the actions the nurse should take in the correct order, starting with the first. All options must be used. Standard Text: Click and drag the options below to move them up or down. Choice 1. Check the victim's breathing. Choice 2. Check the victim's pulse. Choice 3. Check the victim's airway. Choice 4. Immobilize the spine. Choice 5. Check for the victim's responsiveness.

Correct Answer: 5, 3, 1, 2, 4 Rationale 1: All people who have sustained trauma to the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury. Prehospital management includes rapid assessment of the ABCs (airway, breathing, circulation). After the airway is assessed, breathing should be assessed. Rationale 2: All people who have sustained trauma to the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury. Prehospital management includes rapid assessment of the ABCs (airway, breathing, circulation). After breathing is assessed, circulation should be assessed. Rationale 3: All people who have sustained trauma to the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury. Prehospital management includes rapid assessment of the ABCs (airway, breathing, circulation), beginning with the airway. Rationale 4: All people who have sustained trauma to the head or spine, or who are unconscious, should be treated as though they have a spinal cord injury. Prehospital management includes rapid assessment of the ABCs (airway, breathing, circulation) and then immobilizing and stabilizing the head and neck. Rationale 5: In an emergency situation, the nurse first assesses the patient's level of consciousness during the primary survey of CPR.

The nurse assesses a young adult client who was involved in a swimming accident, resulting in tetraplegia. The client makes eye contact with the nurse and states, "I'm going to beat this and walk out of here." Based on this data, which nursing diagnosis is the most appropriate for this client? A) Risk for Post-Trauma Syndrome B) Impaired Physical Mobility C) Self-Care Deficit D) Noncompliance

Answer: A Explanation: The client's statement is unrealistic and is evidence of Risk for Post-Trauma Syndrome. Although the client with tetraplegia does have Impaired Physical Mobility and Self-Care Deficit, this statement is not evidence of those nursing diagnoses. There is no indication of Noncompliance.

An adolescent is brought into the emergency department (ED) with injuries sustained from a motor vehicle crash. What should the nurse ensure while caring for this client? A) An adequate urine output B) Stable blood pressure C) Stabilization of the neck and spinal cord D) Intravenous access line

Answer: C Explanation: The danger of death from a spinal cord injury is greatest when there is damage to or transection of the upper cervical region. All people who have sustained trauma to the spine should be treated as though they have a spinal cord injury by stabilizing the neck and spinal cord. Assessment of urine output can be delayed. Assessing blood pressure is an intervention for all clients brought into the Emergency Department. An intravenous access line is necessary, but the stabilization of the neck and spinal cord is of first priority.

The nurse is evaluating the effectiveness of interventions to address a client's bowel and bladder dysfunction as a result of a spinal cord injury. Which finding would indicate that the interventions have been successful? A) The client had two episodes of impacted stool over the last week. B) The client is improving in ability to perform self-urinary catheterization. C) The client is limiting fluids to reduce need to void. D) The client has an indwelling urinary catheter and is provided with stool softeners every morning.

Answer: B Explanation: An ideal outcome for the client with bowel and bladder dysfunction as a result of a spinal cord injury would be for the client to attain appropriate bowel and bladder elimination habits. If the client's ability to perform self-urinary catheterization is improving, the interventions can be considered successful. The client with an indwelling urinary catheter receiving stool softeners every morning is not progressing toward bowel and bladder elimination habits. The client who had two episodes of impacted stool over the last week is not progressing in bowel elimination habits. The client who is limiting fluids to reduce the need to void is possibly hindering his health in order to avoid having to perform self-urinary catheterization.

A client admitted 3 days prior with an injury to the thoracic area of the spinal cord tells the nurse, "I'm getting worse. It's harder to breathe." Based on this data, which does the nurse suspect? A) The client has atelectasis. B) The extent of injury cannot yet be determined. C) The client is improving. D) The client is developing pneumonia.

Answer: B Explanation: With a spinal cord injury, there is an area of ischemia and edema. Because edema extends from the level of injury for two cord segments above and below the affected level, the extent of injury cannot be determined for up to 1 week. The client's complaint of it being harder to breathe could be evidence that extent of injury is becoming more obvious but will not be totally determined for a few more days. The client's complaint of it being harder to breathe may or may not indicate pneumonia or atelectasis. The complaint is not evidence that the client is improving.

A client who sustained a gunshot wound has symptoms below the level of T-12 of ipsilateral motor paralysis, loss of proprioception and vibratory sense, and contralateral loss of pain and temperature sensation. When planning care for this client, which assumptions by the nurse are appropriate based on the provided data? Select all that apply. A) American Spinal Injury Association Impairment Scale score is A. B) The spinal cord injury is incomplete. C) These findings are consistent with Brown-Sequard syndrome. D) Hemisection of the spinal cord is likely. E) Some recovery of sensory function is higher.

Answer: B, C, D, E Explanation: Hemisection of the spinal cord, usually caused by a penetrating trauma (gunshot, knife), causes sensory and motor deficits on opposite sides of the body because the spinal cord injury is incomplete. These findings are consistent with Brown-Sequard syndrome, which has the best prognosis of all the incomplete spinal cord syndromes. American Spinal Injury Association (ASIA) Impairment Scale (AIS) score of A indicates a complete spinal cord injury where no sensory or motor function is preserved in the sacral segments S4-S5.

The nurse is evaluating the success of a bowel retraining program with a client recovering from a lower motor neuron spinal cord injury. Which observations indicate that this teaching has been successful? Select all that apply. A) One episode of bladder incontinence in 8 hours B) Performs self-urinary catheterization every 4 hours while awake. C) Transfers to use bedside commode after breakfast to evacuate bowels. D) Two episodes of impacted stool in 1 week E) Maintains a high-fluid, high-fiber diet.

Answer: B, C, E Explanation: Evidence that a bowel and bladder retraining program for a client with a spinal cord injury has been successful includes performing self-urinary catheterization every 4 hours while awake, transferring to the bedside commode to evacuate bowels after breakfast, and maintaining a high-fluid and high-fiber diet to prevent constipation. Evidence that this training has not been successful includes an episode of bladder incontinence and the need to impacted stool removed twice in 1 week.

The nurse is teaching an older adult client, and caregiver, regarding appropriate ways to decrease the client's risk for falls. Which interventions are appropriate for the nurse to include in the teaching session? Select all that apply. A) Start aerobic exercises daily. B) Wear sensible shoes with good support when shopping. C) Wear socks when walking in the kitchen. D) Encourage the use of throw rugs throughout the home. E) Make sure hallways and stairways have adequate lighting, even at night.

Answer: B, E Explanation:Interventions that are appropriate to decrease this client's risk for falls include wearing sensible shoes with good support when shopping and making sure hallways and stairways have adequate lighting, even at night. A mild to moderate exercise program is appropriate to improve balance and strength. Nonslip footwear should be encouraged. Throw rugs should be discouraged.

A school nurse is treating a school-age client who has fallen down a flight of stairs. The client is breathing but unconsciousness. After calling the ambulance, which is the priority action by the nurse? A) Open the airway using the head tilt maneuver. B) Try to rouse the client by gently shaking the shoulders. C) Protect the client's neck and head from any movement. D) Place the client on the side to prevent aspiration.

Answer: C Explanation: Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilization of the neck; securing the head; maintaining the client in the supine position; and transferring from the stretcher with backboard in place to the hospital bed. This client is unconscious, and the nurse must protect the neck from any (or any further) damage. If the client vomits, the nurse should utilize the log-roll technique to turn the client while keeping the head, neck, and spine in alignment. The client is breathing; however, if a change in respirations were to occur, the airway should be opened using the jaw thrust maneuver. Rousing the client by shaking could cause damage to the spinal cord.

The nurse in the emergency department is preparing to administer methylprednisolone to a client with a spinal cord injury. Which effect will this medication have on the client? A) Cause an increase in blood glucose level B) Improve the level of consciousness C) Prevent cord damage from ischemia and edema D) Improve the ability to be adequately ventilated

Answer: C Explanation: High-dose steroid protocol using methylprednisolone must be implemented within 8 hours of the injury to improve neurologic recovery. Clinical research indicates that the use of this adrenocorticosteroid is effective in preventing secondary spinal cord damage from edema and ischemia. This medication may cause hyperglycemia if the client also has a diagnosis of diabetes. This medication is not provided to improve respirations or improve the level of consciousness.

The nurse is presenting a talk on spinal cord injury for a community health fair. Which statement indicates that the attendees understand the risk factors and prevention methods associated with spinal cord injury? A) "There isn't much I can do to prevent a head injury when another vehicle hits my car." B) "As long as my grandson wears a helmet, he will be safe on his motorcycle." C) "I'm going to spend extra time discussing this talkmy Boy Scout troop because of their higher risk for spinal cord injury." D) "Due to their high risk, I'd like you to present this talk to the Native American population."

Answer: C Explanation: The highest-risk population for spinal cord injuries is males between 16 and 30 years old. Riding motorcycles increases spinal cord injuries. Native Americans are the ethic group with the lowest risk of spinal cord injury. Using a seat belt is a major preventive action for an individual involved in a motor vehicle accident.

The nurse is planning care for a client admitted with a high thoracic spinal cord injury. Which interventions would be appropriate for the nursing diagnosis of Alteration in Perfusion? Select all that apply. A) Discuss future care needs when discharged. B) Increase fluids to 3,000 mL per day. C) Turn and reposition every 2 hours. D) Assess for a full bladder. E) Assess blood pressure every 2-3 minutes.

Answer: D, E Explanation: An alteration in perfusion can be caused by autonomic dysreflexia, which is an emergency that requires immediate assessment and intervention. The nurse should continue to assess the client's blood pressure every 2-3 minutes in addition to elevating the head of the bed and removing TED hose to encourage the pooling of blood in the extremities and decrease the blood pressure. Once the blood pressure has stabilized or decreased, the nurse can then assess for the stimuli which caused the episode, such as a full bladder. Discussing future care needs when discharged is not a priority at this time, or an intervention for Alteration in Perfusion. Turning the client every 2 hours is not a priority at this time, or an intervention for Alteration in Perfusion.

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly? 1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure

Correct Answer: 1 Rationale 1: Autonomic dysreflexia is triggered by stimuli that would normally cause abdominal discomfort, by stimulation of pain receptors, and by visceral contractions. The most common cause is a full bladder. Rationale 2: Autonomic crisis is not a term used to describe common complications of spinal injury associated with bladder distention. Rationale 3: Autonomic shutdown is not a term used to describe common complications of spinal injury associated with bladder distention. Rationale 4: Autonomic failure is not a term used to describe common complications of spinal injury associated with bladder distention.

A patient recovering from a spinal cord injury (SCI) is experiencing gastric distress. Which medication should the nurse expect to be prescribed for this patient? 1. omeprazole (Prilosec) 2. dopamine (Intropin) 3. baclofen (Lioresal) 4. dantrolene (Dantrium)

Correct Answer: 1 Rationale 1: Proton pump inhibitors such as omeprazole (Prilosec) are often administered to prevent stress-related gastric ulcers, a common complication in SCI. Rationale 2: Vasopressors are used in the immediate acute care phase to treat bradycardia or hypotension due to spinal and neurogenic shock. Dopamine (Intropin) is used to treat hypotension in neurogenic shock. Rationale 3: Antispasmodics such as baclofen (Lioresal) may be used to treat spasticity in patients with spinal cord injury. Rationale 4: Antispasmodics such as dantrolene (Dantrium) may be used to treat spasticity in patients with spinal cord injury. Global Rationale: Proton pump inhibitors such as omeprazole (Prilosec) are often administered to prevent stress-related gastric ulcers, a common complication in SCI. Vasopressors are used in the immediate acute care phase to treat bradycardia or hypotension due to spinal and neurogenic shock. Dopamine (Intropin) is used to treat hypotension in neurogenic shock. Antispasmodics such as baclofen (Lioresal) and dantrolene (Dantrium) may be used to treat spasticity in patients with spinal cord injury.

The nurse is preparing an educational session about spinal cord injury (SCI) prevention for a community group. What patient example should the nurse use to explain the risk factors for this type of injury? 1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 28-year-old female with a history of substance abuse 3. 50-year-old female with osteoporosis 4. 35-year-old male who coaches a soccer team

Correct Answer: 1 Rationale 1: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. Rationale 2: In spite of the substance abuse, this female would have a lower overall risk for SCI than another example. Rationale 3: This female is not at increased risk for spinal cord injuries. Rationale 4: This man is not at increased risk for spinal cord injuries.

An industrial nurse is conducting a class on ways to prevent back pain. What should the nurse include when teaching about lifting heavy objects? Standard Text: Select all that apply. 1. Spread the feet apart to broaden the base of support. 2. Use the legs to push when lifting. 3. Stand as closely as possible to the object to be moved. 4. Roll or push the object instead of lifting. 5. Bend at the waist over the center of gravity.

Correct Answer: 1, 2, 3, 4 Rationale 1: The guidelines for proper body mechanics include spreading the feet apart to broaden the base of support. Rationale 2: The guidelines for proper body mechanics include using the large muscles of the legs to push when lifting. Rationale 3: The guidelines for proper body mechanics include positioning the body as close to the object as possible before lifting or moving it. Rationale 4: The guidelines for proper body mechanics include sliding, rolling, pushing, or pulling an object rather than lifting it. Rationale 5: The guidelines for proper body mechanics include bending the knees and lifting up over one's own center of gravity. Bending at the waist is not recommended.

An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care should be followed? Standard Text: Select all that apply. 1. Immobilize the patient's neck using rolled towels or a cervical collar. 2. Place the patient in a supine position 3. Place the patient on a ventilator. 4. Elevate the head of the bed. 5. Secure the patient's head with a belt or tape secured to the stretcher.

Correct Answer: 1, 2, 5 Rationale 1: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient's neck should be immobilized with rolled towels or a cervical collar. Rationale 2: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient should be maintained in the supine position. Rationale 3: Placement on a ventilator will be considered after admission to the hospital. Rationale 4: Raising the head of the bed will be considered after admission to the hospital. Rationale 5: In the emergency setting, all patients who have sustained a trauma to the head or spine, or are unconscious, should be treated as though they have a spinal cord injury. The patient's head should be secured by placing a belt or tape across the forehead and securing it to the stretcher.

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse? 1. to try to calm the patient and make the environment soothing 2. to assess for a full bladder 3. to notify the healthcare provider 4. to prepare the patient for diagnostic radiography

Correct Answer: 2 Rationale 1: A calm, soothing environment is fine, but not what the patient needs in this case. The nurse should recognize this as an emergency and proceed accordingly. Rationale 2: Autonomic dysreflexia occurs in patients with injury at level T6 or higher and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. Rationale 3: Once the assessment has been completed, the findings will need to be communicated to the healthcare provider. Rationale 4: This would not be an initial response for this patient.

A patient with a spinal cord injury was given IV dexamethasone (Decadron) after arriving in the emergency department. What assessment finding should the nurse attribute to the steroid medication? 1. hypoglycemia 2. less spinal shock 3. urinary retention 4. muscle spasms

Correct Answer: 2 Rationale 1: A common side effect of corticosteroids is hyperglycemia. Rationale 2: In the patient with a spinal cord injury, corticosteroids may be used to reduce or control inflammation and edema of the cord, which can lead to less spinal shock. Rationale 3: Steroids do not cause urinary retention. Rationale 4: Steroids do not cause muscle spasms.

A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds, zero urine output, and palpation of a distended bladder. The nurse realizes that these findings are consistent with which condition? 1. paralysis 2. spinal shock 3. high cervical injury 4. temporary hypovolemia

Correct Answer: 2 Rationale 1: The findings describe paralysis that would be associated with another condition in a spine-injured patient. Rationale 2: Spinal shock is the response of the cord itself to injury. It involves temporary loss of reflex function (areflexia) below the level of injury at the cervical and upper thoracic spinal cord. As a result of the injury, sympathetic function is interrupted and parasympathetic function is unopposed. This condition is characterized by flaccid paralysis, loss of skin reflexes and deep tendon reflexes, and loss of all sensations below the level of injury. There is loss of urinary bladder tone. The autonomic dysfunction results in hypotension. Rationale 3: Lack of respiratory effort is generally associated with high cervical injury. Rationale 4: The likely cause of these findings is not hypovolemia.

The nurse is educating a patient and the family about different types of stabilization devices. Which statement indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs? 1. "I will have less pain if I use the halo device." 2. "The halo device will allow me to get out of bed." 3. "I am less likely to get an infection with the halo device." 4. "The halo device does not have to stay in place as long."

Correct Answer: 2 Rationale 1: The patient's pain level is not dependent on the type of stabilization device used. Rationale 2: Unlike Gardner-Wells tongs, the halo device does not require weights, allowing the patient greater mobility. Rationale 3: Gardner-Wells tongs do not carry a great risk of infection; both devices require pins to be inserted into the skull. Rationale 4: The time required for stabilization is not dependent on the type of stabilization device used.

The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week? 1. "Tissue repair does not begin for 72 hours." 2. "The edema extends the level of injury two cord segments above and below the affected level." 3. "Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses." 4. "Necrosis of gray and white matter does not occur until days after the injury."

Correct Answer: 2 Rationale 1: Tissue repair occurs over a period of 3 to 4 weeks. Rationale 2: Within 24 hours, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost. Because the edema extends above and below the area affected, the extent of injury cannot be determined until after the edema is controlled. Rationale 3: Neurons do not regenerate. Rationale 4: Within 24 hours, necrosis of both gray and white matter begins if ischemia has been prolonged and the function of nerves passing through the injured area is lost.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which actions should the nurse include when caring for this patient? Standard Text: Select all that apply. 1. modifying the traction weights as needed 2. assessing the patient's skin integrity 3. applying the traction upon admission 4. administering pain medication 5. providing passive range of motion

Correct Answer: 2, 4, 5 Rationale 1: The weights on the traction device must not be changed without the order of a healthcare provider. Rationale 2: When caring for a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased risk of skin breakdown. Rationale 3: The healthcare provider is responsible for initially applying the traction device. Rationale 4: The patient in traction is likely to experience pain. The nurse is responsible for assessing the pain and administering the appropriate analgesic as ordered. Rationale 5: Passive range of motion helps prevent contractures; this is often performed by a physical therapist or the nurse.

The nurse suspects that a patient with a spinal cord injury is experiencing autonomic dysreflexia. Which findings will help the nurse determine the cause for this condition? Standard Text: Select all that apply. 1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor 4. diarrhea 5. fecal impaction

Correct Answer: 2, 5 Rationale 1: Hypertension is a manifestation of autonomic dysreflexia. Rationale 2: Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process. Rationale 3: Respiratory system changes do not cause autonomic dysreflexia. Rationale 4: Diarrhea does not cause autonomic dysreflexia. Rationale 5: Fecal impaction can trigger autonomic dysreflexia.

While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is what condition? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

Correct Answer: 3 Rationale 1: Hypoxia is not the most dangerous complication of autonomic dysreflexia. Rationale 2: Bradycardia is not the most dangerous complication of autonomic dysreflexia. Rationale 3: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Rationale 4: Tachycardia is not the most dangerous complication of autonomic dysreflexia.

A victim of a motor vehicle crash has an acute cervical spinal cord injury. Which problem should the nurse identify as the priority for this patient? 1. fluid maintenance 2. changes in mobility 3. problems with the airway 4. altered blood flow

Correct Answer: 3 Rationale 1: There is no reason to believe that this patient will have issues maintaining fluid balance. Rationale 2: Although this patient has a cervical spinal cord injury that will affect mobility, this is not the priority problem at this time. Rationale 3: Because the injury is in the cervical area, the patient is at risk for losing the ability to maintain respirations and clear the airway. This is the priority for the patient at this time. Rationale 4: After another intervention is performed, the next priority problem would be blood flow maintenance.

A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status? 1. hemiplegia 2. paresthesia 3. paraplegia 4. quadriplegia

Correct Answer: 4 Rationale 1: Hemiplegia is paralysis on one side of the body. Rationale 2: Paresthesia does not include paralysis. Rationale 3: Paraplegia is paralysis of the lower body. Rationale 4: Quadriplegia is the complete paralysis of the upper extremities and lower part of the body.

A hospitalized patient with a C7 cord injury yells, "I can't feel my legs anymore." Which is the most appropriate action by the nurse? 1. remind the patient of her injury and try to comfort her 2. call the healthcare provider and get an order for radiologic evaluation 3. prepare the patient for surgery, as her condition is worsening 4. explain to the patient that this could be a common, temporary problem

Correct Answer: 4 Rationale 1: The nurse should explain to the patient what is happening. Rationale 2: The healthcare provider does not need to be contacted. Radiologic evaluation is not necessary. Rationale 3: Surgery is not indicated at this point as loss of sensation below the injury may occur. Rationale 4: Spinal shock is a condition almost half the people with acute spinal injury experience. It is characterized by a temporary loss of reflex function below level of injury and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, possibly bowel and bladder dysfunction, and loss of ability to perspire below the injury level.