Spinal Cord Injury
Two days following a spinal cord injury, 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 reflex 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 effect will be."
. b. Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1 week after the injury, it is not possible to determine how much cord damage is present from the initial injury, how much secondary injury occurred, or how much the cord was damaged by edema that extended above the level of the original injury. The return of reflexes signals only the end of spinal shock and the reflexes may be inappropriate and excessive, causing spasms that complicate rehabilitation.
A week following a spinal cord injury at T2, a patient experiences movement in his leg and tells the nurse that he is recovering some function. What is the nurse's best response to the patient? 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. When spinal shock ends, reflex movement and spasms will occur, which may be mistaken for return of function; however, with the resolution of edema, some normal function may also occur. It is important when movement occurs to determine whether the movement is voluntary and can be consciously controlled, which would indicate some return of function
A patient with neurogenic shock following a spinal cord injury is to receive lactated Ringer's solution 500 mL over 30 minutes. When setting the IV pump to deliver the IV fluid, the nurse will set the rate at how many mL/hour?
ANS: 1000 To administer 500 mL in 30 minutes, the nurse will need to set the pump to run at 1000 mL/hour.
Which nursing action has the highest priority for a patient who was admitted 16 hours previously with a C5 spinal cord injury? a. Cardiac monitoring for bradycardia b. Assessment of respiratory rate and effort c. Application of pneumatic compression devices to legs d. Administration of methylprednisolone (Solu-Medrol) infusion
ANS: B Edema around the area of injury may lead to damage above the C4 level, so the highest priority is assessment of the patient's respiratory function. Methylprednisolone (Solu-Medrol) is no longer recommended for the treatment of spinal cord injuries. The other actions also are appropriate but are not as important as assessment of respiratory effort.
How is urinary function maintained during the acute phase of spinal cord injury? a. An indwelling catheter b. Intermittent catheterization c. Insertion of a suprapubic catheter d. Use of incontinent pads to protect the skin
a. During the acute phase of spinal cord injury, the bladder is hypotonic, causing urinary retention with the risk for reflux into the kidney or rupture of the bladder. An indwelling catheter is used to keep the bladder empty and to monitor urinary output. Intermittent catheterization or other urinary drainage methods may be used in longterm bladder management. Use of incontinent pads is inappropriate because they do not help the bladder to empty.
Without surgical stabilization, what method of immobilization for the patient with a cervical spinal cord injury 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
c. The development of better surgical stabilization has made surgery the more frequent treatment of cervical injuries. However, when surgery cannot be done, skeletal traction with the use of Crutchfield, Vinke, or other types of skull tongs is required to immobilize the cervical vertebrae, even if a fracture has not occurred. Hard cervical collars or a sternal-occipitalmandibular immobilizer brace may be used after cervical stabilization surgery or for minor injuries or stabilization during emergency transport of the patient. Sandbags may also be used temporarily to stabilize the neck during insertion of tongs or during diagnostic testing immediately following the injury. Special turning or kinetic beds may be used to turn and mobilize patients who are in cervical traction.
In counseling patients with spinal cord lesions regarding sexual function, how should the nurse advise a male patient with a complete lower motor neuron lesion? a. He is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs. b. He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible. c. He has a lesion with the greatest possibility of successful psychogenic erection with ejaculation and orgasm. d. He will probably be unable to have either psychogenic or reflexogenic erections and no ejaculation or orgasm.
d. Most patients with a complete lower motor neuron lesion are unable to have either psychogenic or reflexogenic erections and alternative methods of obtaining sexual satisfaction may be suggested. Patients with incomplete lower motor neuron lesions have the highest possibility of successful psychogenic erections with ejaculation whereas patients with incomplete upper motor neuron lesions are more likely to experience reflexogenic erections with ejaculation. Patients with complete upper motor neuron lesions usually have only reflex sexual function with rare ejaculation.
In which order will the nurse perform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the emergency department? (Put a comma and a space between each answer choice [A, B, C, D, E].) a. Infuse normal saline at 150 mL/hr. b. Monitor cardiac rhythm and blood pressure. c. Administer O2 using a non-rebreather mask. d. Immobilize the patient's head, neck, and spine. e. Transfer the patient to radiology for spinal computed tomography (CT).
ANS: D, C, B, A, E The first action should be to prevent further injury by stabilizing the patient's spinal cord if the patient does not have penetrating trauma. Maintenance of oxygenation by administration of 100% O2 is the second priority. Because neurogenic shock is a possible complication, monitoring of heart rhythm and BP are indicated, followed by infusing normal saline for volume replacement. A CT scan to determine the extent and level of injury is needed once initial assessment and stabilization are accomplished.
Following a cauda equina spinal cord injury, which action will the nurse include in the plan of care? a. Catheterize patient every 3 to 4 hours. b. Assist patient to ambulate several times daily. c. Administer medications to reduce bladder spasm. d. Stabilize the neck when repositioning the patient.
ANS: A Patients with cauda equina syndrome have areflexic bladder, and intermittent catheterization will be used for emptying the bladder. Because the bladder is flaccid, antispasmodic medications will not be used. The legs are flaccid with cauda equina syndrome and the patient will be unable to ambulate. The head and neck will not need to be stabilized following a cauda equina injury, which affects the lumbar and sacral nerve roots.
A 39-year-old patient is being evaluated for a possible spinal cord tumor. Which finding by the nurse requires the most immediate action? a. The patient has new onset weakness of both legs. b. The patient complains of chronic severe back pain. c. The patient starts to cry and says, "I feel hopeless." d. The patient expresses anxiety about having surgery.
ANS: A The new onset of symptoms indicates cord compression, which is an emergency that requires rapid treatment to avoid permanent loss of function. The other patient assessments also indicate a need for nursing action but do not require intervention as rapidly as the new onset weakness.
When caring for a patient who experienced a T2 spinal cord transection 24 hours 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. Maintain a warm room temperature e. Administration of H2 receptor blockers
ANS: A, C, D, E The patient is at risk for bradycardia and poikilothermia caused by sympathetic nervous system dysfunction and should have continuous cardiac monitoring and maintenance of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and NG suctioning is indicated. To avoid bladder distention, a urinary retention catheter is used during this acute phase. Stress ulcers are a common complication, but can be avoided through the use of the H2 receptor blockers such as famotidine.
A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? a. Teach the patient the Credé method. b. Instruct the patient how to self-catheterize. c. Catheterize for residual urine after voiding. d. Assist the patient to the toilet every 2 hours.
ANS: B Because the patient's bladder is spastic and will empty in response to overstretching of the bladder wall, the most appropriate method is to avoid incontinence by emptying the bladder at regular intervals through intermittent catheterization. Assisting the patient to the toilet will not be helpful because the bladder will not empty. The Credé method is more appropriate for a bladder that is flaccid, such as occurs with areflexic neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
A 20-year-old patient who sustained a T2 spinal cord injury 10 days ago angrily tells the nurse "I want to be transferred to a hospital where the nurses know what they are doing!" Which action by the nurse is best? a. Clarify that abusive language will not be tolerated. b. Request that the patient provide input for the plan of care. c. Perform care without responding to the patient's comments. d. Reassure the patient about the competence of the nursing staff.
ANS: B The patient is demonstrating behaviors consistent with the anger phase of the grief process, and the nurse should allow expression of anger and seek the patient's input into care. Expression of anger is appropriate at this stage, and should be accepted by the nurse. Reassurance about the competency of the staff will not be helpful in responding to the patient's anger. Ignoring the patient's comments will increase the patient's anger and sense of helplessness.
When the nurse is developing a rehabilitation plan for a 30-year-old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to a. drive a car with powered hand controls. b. push a manual wheelchair on a flat surface. c. turn and reposition independently when in bed. d. transfer independently to and from a wheelchair.
ANS: B The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
The nurse will explain to the patient who has a T2 spinal cord transection injury that a. use of the shoulders will be limited. b. function of both arms should be retained. c. total loss of respiratory function may occur. d. tachycardia is common with this type of injury.
ANS: B The patient with a T2 injury can expect to retain full motor and sensory function of the arms. Use of only the shoulders is associated with cervical spine injury. Loss of respiratory function occurs with cervical spine injuries. Bradycardia is associated with injuries above the T6 level.
A 38-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 unassisted during rehabilitation. The most appropriate action by the nurse at this time is to a. remind the patient about the importance of independence in daily activities. b. tell the spouse to stop because the patient is able to perform activities independently. c. develop a plan to increase the patient's independence in consultation with the patient and the spouse. d. recognize that it is important for the spouse to be involved in the patient's care and encourage that participation.
ANS: C The best action by the nurse will be to involve all the parties in developing an optimal plan of care. Because family members who will be assisting with the patient's ongoing care need to feel that their input is important, telling the spouse that the patient can perform activities independently is not the best choice. Reminding the patient about the importance of independence may not change the behaviors of the spouse. Supporting the activities of the spouse will lead to ongoing dependency by the patient.
A 33-year-old patient with a T4 spinal cord injury asks the nurse 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.
ANS: C Although sexuality will be changed by the patient's spinal cord injury, there are options for expression of sexuality and for fertility. The other information also is correct, but the choices will depend on the degrees of injury and the patient's individual feelings about sexuality.
A patient who had a C7 spinal cord injury a week ago has a weak cough effort and audible rhonchi. The initial intervention by the nurse should be to a. administer humidified oxygen by mask. b. suction the patient's mouth and nasopharynx. c. push upward on the epigastric area as the patient coughs. d. encourage incentive spirometry every 2 hours during the day.
ANS: C Because the cough effort is poor, the initial action should be to use assisted coughing techniques to improve the ability to mobilize secretions. Administration of oxygen will improve oxygenation, but the data do not indicate hypoxemia. The use of the spirometer may improve respiratory status, but the patient's ability to take deep breaths is limited by the loss of intercostal muscle function. Suctioning may be needed if the patient is unable to expel secretions by coughing but should not be the nurse's first action.
Which nursing action will the home health nurse include in the plan of care for a patient with paraplegia at the T4 level in order to prevent autonomic dysreflexia? a. Support selection of a high-protein diet. b. Discuss options for sexuality and fertility. c. Assist in planning a prescribed bowel program. d. Use quad coughing to strengthen cough efforts.
ANS: C Fecal impaction is a common stimulus for autonomic dysreflexia. Dietary protein, coughing, and discussing sexuality/fertility should be included in the plan of care but will not reduce the risk for autonomic dysreflexia.
The nurse is admitting a patient with a neck fracture at the C6 level to the intensive care unit. Which assessment finding(s) indicate(s) neurogenic shock? a. Hyperactive reflex activity below the level of injury b. Involuntary, spastic movements of the arms and legs c. Hypotension, bradycardia, and warm, pink extremities d. Lack of sensation or movement below the level of injury
ANS: C Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement and sensation indicate spinal cord injury, but not neurogenic shock.
A patient admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach." Which action should the nurse take first? a. Check for a fecal impaction. b. Give the prescribed analgesic. c. Assess the blood pressure (BP). d. Notify the health care provider.
ANS: C The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. After checking the BP, the nurse may assess for a fecal impaction using lidocaine jelly to prevent further increased BP.
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Séquard syndrome. Which nursing action should be included in the plan of care? a. Assessment of the patient for right arm weakness b. Assessment of the patient for increased right leg pain c. Positioning the patient's left leg when turning the patient d. Teaching the patient to look at the right leg to verify its position
ANS: C The patient with Brown-Séquard syndrome has loss of motor function on the ipsilateral side and will require the nurse to move the left leg. Pain sensation will be lost on the patient's right leg. Arm weakness will not be a problem for a patient with a T7 injury. The patient will retain position sense for the right leg.
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. Global Rationale: 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. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms 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. Global Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse. In spite of the substance abuse, the 28-year-old female would have a lower overall risk for SCI than another example. The 50-year-old female with osteoporosis and the 35-year-old male who coaches a soccer team are not at increased risk for SCI.
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. Global Rationale: 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. The patient should be maintained in the supine position. The head should be secured by placing a belt or tape across the forehead and securing it to the stretcher. Placement on a ventilator and raising the head of the bed will be considered after admission to the hospital.
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. Global Rationale: 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. 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. Once the assessment has been completed, the findings will need to be communicated to the healthcare provider.
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. Global Rationale: 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. A common side effect of corticosteroids is hyperglycemia. Steroids do not cause urinary retention or 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. Global Rationale: 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. Lack of respiratory effort is generally associated with high cervical injury. The findings describe paralysis that would be associated with spinal shock in a spine-injured patient. The likely cause of these findings is not hypovolemia, but rather spinal shock.
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. Global Rationale: Unlike Gardner-Wells tongs, the halo device does not require weights, allowing the patient greater mobility. The patient's pain level and the time required for stabilization are not dependent on the type of stabilization device used. Gardner-Wells tongs do not carry a great risk of infection; both devices require pins to be inserted into the skull.
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. Global Rationale: 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. Neurons do not regenerate. Tissue repair occurs over a period of 3 to 4 weeks.
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. Global Rationale: 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. The patient in traction is likely to experience pain. The nurse is responsible for assessing the pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or the nurse. The healthcare provider is responsible for initially applying the traction device. The weights on the traction device must not be changed without the order of a healthcare provider.
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. Global Rationale: 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. Fecal impaction can trigger autonomic dysreflexia. Hypertension is a manifestation of autonomic dysreflexia. Respiratory system changes and diarrhea do not cause autonomic dysreflexia.
A school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, what should the nurse do? 1. assess the neck for movement 2. place the patient on the side to prevent aspiration 3. immobilize the neck, securing the head 4. try to rouse the patient by gently shaking the shoulders
Correct Answer: 3 Rationale 1: Guidelines for emergency care include avoiding flexing, extending, or rotating the neck. Assessing the neck for movement could cause or exacerbate a cervical injury. Rationale 2: If the patient vomits, the nurse should use the log-roll technique to turn the patient while keeping the head, neck, and spine in alignment. However, the side-lying position should not be used in the immediate emergency care of this patient. Rationale 3: Guidelines for emergency care include immobilizing the neck and securing the head. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. Rationale 4: Rousing the patient by shaking could cause damage to the spinal cord. Global Rationale: Guidelines for emergency care include avoiding flexing, extending, or rotating the neck; immobilizing the neck; and securing the head. Assessing the neck for movement could cause or exacerbate a cervical injury. The side-lying position should be used if the patient vomits; however, this position should not be used in the immediate care of this patient. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. Rousing the patient by shaking could cause damage to the spinal cord.
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. Global Rationale: Autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. Hypoxia, bradycardia, and tachycardia are not the most dangerous complications 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. Global Rationale: 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. There is no reason to believe that this patient will have issues maintaining fluid balance. Although the patient has a cervical spinal cord injury that will affect mobility, this is not the priority problem at this time. Once the patient's airway is secured 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. Global Rationale: Quadriplegia is the complete paralysis of the upper extremities and the lower part of the body. Hemiplegia is paralysis on one side of the body, and paraplegia is paralysis of the lower body. Paresthesia does not include paralysis.
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. Global Rationale: 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. The nurse should explain to the patient what is happening. The healthcare provider does not need to be contacted. Radiologic evaluation is not necessary and surgery is not indicated.
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. Global Rationale: In an emergency situation, the nurse first assesses the patient's level of consciousness during the primary survey of CPR. 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.
9. In planning community education for prevention of spinal cord injuries, what group should the nurse target? a. Older men b. Teenage girls c. Elementary school-age children d. Adolescent and young adult men
D. Spinal cord injuries are highest in adolescent and young adult men between the ages of 16 and 30 and those who are impulsive or risk takers in daily living. Other risk factors include alcohol and drug abuse as well as participation in sports and occupational exposure to trauma or violence
Priority Decision: A patient with a spinal cord injury suddenly experiences a throbbing headache, flushed skin, and diaphoresis above the level of injury. After checking the patient's vital signs and finding a systolic blood pressure of 210 and a heart rate of 48 bpm, number the following nursing actions in order of priority from highest to lowest (begin with number 1 as first priority) a. Administer ordered prn nifedipine (Procardia). __________ b. Check for bladder distention. __________ c. Document the occurrence, treatment, and response. __________ d. Place call to physician. __________ e. Raise the head of bed (HOB) to 45 degrees or above. __________ f. Loosen tight clothing on the patient.
a. 5; b. 2; c. 6; d. 3; e. 1; f. 4. The patient is experiencing autonomic dysreflexia. The initial response by the nurse should be to elevate the head of bed (HOB) to decrease blood pressure (BP) and then to remove noxious stimulation. Frequently the trigger is bladder distention, which can be dealt with quickly. The physician needs to be notified as soon as possible and, depending on the communication system available to the nurse, he or she should have the call placed. Meanwhile, the nurse should stay with the patient and loosen any restrictive clothing. The physician may order an antihypertensive and documentation should be an accurate and thorough description of the entire episode
Which syndrome of incomplete spinal cord lesion is described as cord damage common in the cervical region resulting in greater weakness in upper extremities than lower? a. Central cord syndrome b. Anterior cord syndrome c. Posterior cord syndrome d. Cauda equina and conus medullaris syndromes
a. In central cord syndrome, motor weakness and sensory loss are present in both upper and lower extremities, with upper extremities affected more than lower extremities.
Priority Decision: 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 sympathetic nervous system d. GI hypomotility with paralytic ileus and gastric distention
a. Spinal injury below C4 will result in diaphragmatic breathing and usually hypoventilation from decreased vital capacity and tidal volume from intercostal muscle impairment. The nurse's priority actions will be to monitor rate, rhythm, depth, and effort of breathing to observe for changes from the baseline and identify the need for ventilation assistance. Loss of all respiratory muscle function occurs above C4 and the patient requires mechanical ventilation to survive. Although the decreased sympathetic nervous system response (from injuries above T6) and GI hypomotility (paralytic ileus and gastric distention) will occur (with injuries above T5), they are not the patient's initial priority needs.
Priority Decision: A patient is admitted to the emergency department with a possible cervical spinal cord injury following an automobile crash. During admission of the patient, what is the highest priority for the nurse? a. Maintaining a patent airway b. Maintaining immobilization of the cervical spine c. Assessing the patient for head and other injuries d. Assessing the patient's motor and sensory function
a. The need for a patent airway is the first priority for any injured patient and a high cervical injury may decrease the gag reflex and the ability to maintain an airway as well as the ability to breathe. Maintaining cervical stability is then a consideration, along with assessing for other injuries and the patient's neurologic status.
During the patient's process of grieving for the losses resulting from spinal cord injury, 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 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
a. Working through the grief process is a lifelong process that is triggered by new experiences, such as marriage, child rearing, employment, or illness, which the patient must adjust to throughout life within the context of his or her disability. The goal of recovery is related to adjustment rather than acceptance and many patients do not experience all components of the grief process. During the anger phase, patients should be allowed outbursts and the nurse m
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
b. At the C7 level, spinal shock is manifested by tetraplegia and sensory loss. The neurologic loss may be temporary or permanent. Paraplegia with sensory loss would occur at the level of T1. A hemiplegia occurs with central (brain) lesions affecting motor neurons and spastic tetraplegia occurs when spinal shock resolves.
The patient is diagnosed with Brown-Séquard syndrome after a knife wound to the spine. Which description accurately describes this syndrome? a. Damage to the most distal cord and nerve roots, resulting in flaccid paralysis of the lower limbs and areflexic bowel and bladder b. Spinal cord damage resulting in ipsilateral motor paralysis and contralateral loss of pain and sensation below the level of the lesion c. Rare cord damage resulting in loss of proprioception below the lesion level with retention of motor control and temperature and pain sensation d. Often caused by flexion injury with acute compression of cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury
b. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and position and vibratory sense and vasomotor paralysis with contralateral loss of pain and temperature sensation below the level of the injury. Damage to the most distal cord and nerve roots with flaccid paralysis of the lower limbs and areflexic bowel and bladder is seen with cauda equine syndrome or conus medullaris syndrome. Posterior cord syndrome is rare, with cord damage resulting in loss of proprioception below the lesion level but retention of motor control and temperature and pain sensation. Anterior cord syndrome is often caused by flexion injury, with acute compression of the cord resulting in complete motor paralysis and loss of pain and temperature sensation below the level of injury but touch, position, vibration, and motion remaining intact.
A patient with paraplegia has developed an irritable bladder with reflex emptying. 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. Intermittent self-catheterization five to six times a day is the recommended method of bladder management for the patient with a spinal cord injury and reflexic neurogenic bladder because it more closely mimics normal emptying and has less potential for infection. The patient and family should be taught the procedure using clean technique and if the patient has use of the arms, self-catheterization should be performed. Indwelling catheterization is used during the acute phase to prevent overdistention of the bladder and surgical urinary diversions are used if urinary complications occur
A patient with a metastatic tumor of the spinal cord is scheduled for removal of the tumor by a laminectomy. In planning postoperative care for the patient, what should the nurse recognize? a. Most cord tumors cause autodestruction of the cord as in traumatic injuries. b. Metastatic tumors are commonly extradural lesions that are treated palliatively. c. Radiation therapy is routinely administered following surgery for all malignant spinal cord tumors. d. Because complete removal of intramedullary tumors is not possible, the surgery is considered palliative.
b. Most metastatic or secondary tumors are extradural lesions in which treatment, including surgery, is palliative. Primary spinal tumors may be removed with the goal of cure. Most tumors of the spinal cord are slow-growing, do not cause autodestruction, and, if removal is possible, can have complete function restored. Radiation is used to treat metastatic tumors that are sensitive to radiation and that have caused only minor neurologic deficits in the patient. Radiation is also used as adjuvant therapy to surgery for intramedullary tumors.
A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse? a. SpO2 of 92% b. Heart rate of 42 bpm c. Blood pressure of 88/60 mm Hg d. Loss of motor and sensory function in arms and legs
b. Neurogenic shock associated with cord injuries above the level of T6 greatly decreases the effect of the sympathetic nervous system and bradycardia and hypotension occur. A heart rate of 42 bpm is not adequate to meet the oxygen needs of the body. While low, the blood pressure is not at a critical point. The oxygen saturation is satisfactory and the motor and sensory losses are expected.
Priority Decision: During assessment of a patient with a spinal cord injury, 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 endotracheal intubation and mechanical ventilation.
c. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient's breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment. Suctioning is not indicated unless lung sounds indicate retained secretions. Position changes will help to mobilize secretions. Intubation and mechanical ventilation are used if the patient becomes exhausted from labored breathing or if arterial blood gases (ABGs) deteriorate
The health care provider has ordered IV dopamine (Intropin) for a patient in the emergency department with a spinal cord injury. The nurse determines that the drug is having the desired effect when what is observed in patient assessment? a. Heart rate of 68 bpm b. Respiratory rate of 24 c. Blood pressure of 106/82 mm Hg d. Temperature of 96.8°F (36.0°C)
c. Dopamine is a vasopressor that is used to maintain blood pressure during states of hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine would be used to treat bradycardia. The temperature reflects some degree of poikilothermism but this is not treated with medications
A patient with a spinal cord injury 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, hyperreflexia, and reflex emptying of the bladder. d. The patient will have complete loss of motor and sensory functions below the level of the injury but autonomic functions are not affected.
c. Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of most processes without any reflex activity. Return of reflex activity, although hyperreflexive and spastic, signals the end of spinal shock. Rehabilitation activities are not contraindicated during spinal shock and should be instituted if the patient's cardiopulmonary status is stable. Neurogenic shock results from loss of vascular tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased cardiac output (CO). Sympathetic function is impaired below the level of the injury because sympathetic nerves leave the spinal cord at the thoracic and lumbar areas and cranial parasympathetic nerves predominate in control over respirations, heart, and all vessels and organs below the injury, which includes autonomic functions.
What causes an initial incomplete spinal cord injury to result in complete cord damage? a. Edematous compression of the cord above the level of the 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
c. The primary injury of the spinal cord rarely affects the entire cord but the pathophysiology of secondary injury may result in damage that is the same as mechanical severance of the cord. Complete cord dissolution occurs through autodestruction of the cord by hemorrhage, edema, and the presence of metabolites and norepinephrine, resulting in anoxia and infarction of the cord. Edema resulting from the inflammatory response may compress the spinal cord as well as increase the damage as it extends above and below the injury site.
The patient's spinal cord injury is at T4. What is the highest-level goal of rehabilitation that is realistic for this patient to have? a. Indoor mobility in manual wheelchair b. Ambulate with crutches and leg braces c. Be independent in self-care and wheelchair use d. Completely independent ambulation with short leg braces and canes
c. With the injury at T4, the highest-level realistic goal for this patient is to be able to be independent in self-care and wheelchair use because arm function will not be affected. Indoor mobility in a manual wheelchair will be achievable but it is not the highest-level goal. Ambulating with crutches and leg braces can be achieved only by patients with injuries in T6-12 area. Independent ambulation with short leg braces and canes could occur for a patient with an L3-4 injury.
What is one indication for early surgical therapy of the patient with a spinal cord injury? a. There is incomplete cord lesion involvement. b. The ligaments that support the spine are torn. c. A high cervical injury causes loss of respiratory function. d. Evidence of continued compression of the cord is apparent.
d. Although surgical treatment of spinal cord injuries often depends on the preference of the health care provider, surgery is usually indicated when there is continued compression of the cord by extrinsic forces or when there is evidence of cord compression. Other indications may include progressive neurologic deficit, compound fracture of the vertebra, bony fragments, and penetrating wounds of the cord.
Following a T2 spinal cord injury, 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
d. During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur and nasogastric suction must be used to remove secretions and gas from the GI tract until peristalsis resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic ileus. Tube feedings would be used only for patients who have difficulty swallowing and not until peristalsis returns. Parenteral nutrition would be used only if the paralytic ileus was unusually prolonged.
