Week #9: Spinal Cord Injuries

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a. absence of reflexes along with flaccid extremities b. Positive Babinski's reflex along with spastic extremities c. Hyperreflexia along with spastic extremities d. spasticity of all four extremities

a. absence of reflexes along with flaccid extremities spinal shock causes an absence of reflexes & flaccid extremities (spasticity occurs in recovery)

Which of the following clinical manifestations would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? a. bradycardia b. hypertension c. neurogenic spasticity d. bounding pedal pulses

a. bradycardia

A nurse is caring for a client with a complete T5 SCI. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a BP of 162/96. The client reports a severe, pounding HA. Which nursing interventions are appropriate for this client? SATA a. elevating the HOB to 90 degrees b. loosening constrictive clothing c. using a face to reduce diaphoresis d. assessing for bladder distention & bowel impaction e. admin antihypertensive meds f. placing the client in a supine position with legs elevated

a. elevating the HOB to 90 degrees b. loosening constrictive clothing d. assessing for bladder distention & bowel impaction e. admin antihypertensive meds fix the diaphoresis patient should be sat up- otherwise worsen BP

A nurse in the ED assesses a client injured in a diving accident 2 hours earlier. A CT reveals a fracture of the C4 vertebrae. The client is breathing independently but has no movement of muscle tone from below the area of injury. The nurse understands that the client: a. has suffered a complete SCI b. is experiencing spinal shock c. has sustained an upper motor neuron injury d. will be a quadriplegic

b. is experiencing spinal shock

A client has a C7 spinal cord injury. Which of the following would be the most important nursing intervention during the acute stage of the injury? a. turning & repositioning every 2 hours b. maintaining proper alignment c. maintaining a patent airway d. monitoring vital signs

c. maintaining a patent airway ABCs

During assessment of a patient with a spinal cord injury at the level of T2 at the rehab center, which of the following findings would concern the nurse the most? a. A HR of 92 b. A reddened area over the patient's coccyx c. marked perspiration on the patient's face and arms d. a light inspiratory wheeze on auscultation of the lungs

c. marked perspiration on the patient's face and arms this could be a sign of autonomic dysreflexia

When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest priority? a. risk for impairment of tissue integrity caused by paralysis b. altered patterns of urinary elimination caused by quadriplegia c. altered family and individual coping caused by the extent of trauma d. ineffective airway clearance caused by high cervical spinal cord injury

d. ineffective airway clearance caused by high cervical spinal cord injury