SCI Pearson Test 2

3 (Autonomic dysreflexia is a LIFE THREAT condition that can be considered a medical emergency requiring immed. attention. The nurse should not assess but should intervene. The MOST COMMON CAUSE is a full bladder. Autonomic dysreflexia is a complication above T6)

11. The client with a C-6 SCI comes to the ED complaining of a throbbing headache and has a BP of 200/120 Which intervention should the nurse implement first? 1 Place the client on telemetry unit 2. Complete a neurological assessment 3. Insert an indwelling catheter 4. REquest a STAT CT scan on the head

2 (The UAP's training and education covers measuring and recording vital signs. The UAP may help with turning and repositioning the client and may remind the client to cough and deep breathe, but he or she does not teach the client how to perform these actions. Assessing and monitoring clients require additional education and are appropriate to the scope of practice of professional nurses. Focus: Delegation, supervision)

11. You are floated from the ED to the neurologic floor. Which action should you delegate to the UAP when providing nursing care for a client with an SCI? 1. Assessing the client's respiratory status every 4 hours 2. Taking the client's vital signs and recording every 4 hours 3. Monitoring the client's nutritional status, including calorie counts 4. Instructing the client how to turn, cough, and breathe deeply every 2 hours

1,3,4 ( Checking and observing for signs of pressure or infection is within the scope of practice of the LPN/LVN. The LPN/LVN also has the appropriate skills for cleaning the halo insertion sites with hydrogen peroxide. Neurologic examination and care plan development require additional education and skill appropriate to the professional RN. Focus: Delegation, supervision)

13. A client with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this client, the nurse may delegate which actions to an LPN/LVN? (Select all that apply.) 1. Checking the client's skin for pressure from the device 2. Assessing the client's neurologic status for changes 3. Observing the halo insertion sites for signs of infection 4. Cleaning the halo insertion sites with hydrogen peroxide 5. Developing the nursing plan of care for the client

3 ( The client's statement indicates impaired individual resilience in adjusting to the limitations of the injury and the need for additional counseling, teaching, and support. The other three nursing diagnoses may be appropriate for a client with SCI but are not related to the client's statement. Focus: Prioritization)

14. You are preparing a nursing care plan for a client with an SCI for whom the nursing diagnoses of Impaired Physical Mobility and Toileting Self-Care Deficit have been identified. The client tells you, "I don't know why we're doing all this. My life's over." Based on this statement, which additional nursing diagnosis takes priority? 1. Risk for Injury related to altered mobility 2. Imbalanced Nutrition: Less than Body Requirements 3. Impaired Individual Resilience related to spinal cord injury 4. Disturbed Body Image related to immobilization

2 (2 The traveling nurse is relatively new to neurologic nursing and should be assigned clients whose condition is stable and not complex, such as the client with chronic ALS. The newly-diagnosed client with MS will need a lot of teaching and support. The client with respiratory distress will need frequent assessments and may need to be transferred to the intensive care unit. The client with a C4-level SCI is at risk for respiratory arrest. All three of these clients should be assigned to nurses experienced in neurologic nursing care. Focus: Assignment)

15. Which client should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week? 1. 34-year-old with newly diagnosed multiple sclerosis (MS) 2. 68-year-old with chronic amyotrophic lateral sclerosis (ALS) 3. 56-year-old with Guillain-Barré syndrome (GBS) in respiratory distress 4. 25-year-old admitted with a C4-level SCI

4 (This client should be categorized as black priority 4, which means the injury is extensive and chances of survival are unlikely even with definitive care. Clients should receive comfort measures and be separated from other casualties but not abandoned WRONG: #3 is priority 2, yellow meaning injury is significant and requires care but can wait hours. #2 This client is priority 3 meaning minor and can have tx delayed hours. #1 Is a RED priority 1, injury is life threatening, but survivable with minimal intervention this client could deteriorate rapidly without treatment)

35 The community health nurse is triaging victims at the site of a disaster. Which client should the nurse categorize as black, priority 4? 1. The client who is alert and has a sucking chest wound 2. The client who cannot stop crying and cant answer questions 3. The client whose abdomen is hard and tender to touch 4. The client who has full thickness burns over 6o% of the body

4 (This client is reporting infection at insertion sites into the bone. Which can lead to osteomylitis. The client is exhibiting a potentially life threatening condition and should be seen first. WRONG #1 a severe pounding headache would be a priority for a client with a T-6 or above SCI, because it could be autonomic dysreflexia, but not in a client with a lower level lesion. )

38 The HH nurse is scheduling clients for the day. Which client should the nurse visit first? 1. The client with a L-4 SCI who is complaining of a severe pounding headache 2. The client with AMS who is depressed and wants to die 3. The client with Parkinsons who is walking with a short shuffling gait 4. The client with a C-5 SCI who reports redness and drainage at the Halo Vest sites

2,3,5 (The client with a C3-C4 fracture has neck control but may tire easily using sore muscles around the incision area to hold up the head. Therefore, the head and neck of the wheelchair should be high. The seat of the wheelchair should be lower than normal to facilitate transfer from the bed to the wheelchair. When a client can use the hands and arms to move the wheelchair, the placement of the back to the clients scapula is necessary. This client cannot use the arms and will need an electric chair with breath, chin, or voice control.. A firm or hard cushion adds pressure to bony prominences The cushion should be padded to reduce the risk of pressure ulcers)

4 days after surgery for internal fixation of a C3-C4 fracture a nurse is moving a client from the bed to the wheelchair The nurse is checking the wheelchair for correct features for this client. Which features of the wheelchair are appropriate for the needs of this client? SATA 1. back at the level of the clients scapula 2 back and head that are high 3. seat that is lower than normal 4. seat with firm cushions 5. chair controlled by the clients breath

1 (The client with a closed head injury is at risk for ICP. and the osmotic diuretic is the priority med. WRonG: #4 is a scheduled med, #3 needs assessment #2 should admin prior to PT but not life threatening as is #1)

64 The nurse is administering medications on a neuro unit. Which meds should the nurse administer first? 1. The osmotic diuretic to the client with the closed head injury 2. The morning meds to the client scheduled for physical therapy 3. The narcotic pain med to the client with ICP 4. The anticonvulsant gabapentin to the client with restless leg syndrom

a,b,e (Rationale ​Gardner-Wells tongs are pins applied through the skull and weights attached to provide cervical traction. The client remains in bed with​ his/her body used as a​ counter-weight to the weights applied to the pins.A halo external fixation device is attached to a brace and is used to stabilize fractures of the cervical and upper thoracic region without major cord damage or extradural lesions. It is applied with four pins inserted into the skull.Decompression surgery is done when major cord damage and external bleeding occurs.)

A client with a​ C5-C6-C7 fracture is scheduled for placement of a halo external fixation device. Which education should the nurse provide to the client about this​ device? ​(Select all that​ apply.) a The device is applied with four pins inserted into the skull b The device is used to stabilize fractures of the cervical and upper thoracic region c The device is used to decompress the spinal cord d The device consists of pins applied through the skull and weights attached to provide cervical traction e The device is used for cervical fractures without major cord damage or extradural lesions

1,3,5 (The nurse has asked the client to move the arm on the bed. The nurse has asked the client to move the arm against the nurse's resistance. The nurse has asked the client to dangle the arm off the bed and move it. The last part of this assessment is to determine whether movement and strength are normal against resistance. Moving the extremity against gravity is the second assessment. )

A nurse documents that a client with an SCI has full strength in the left arm on initial assessment. Which actions has this nurse taken? Select all that apply. 1 The nurse has asked the client to move the arm against the nurse's resistance. 2 The nurse asks the client to bend at the waist and touch the floor. 3 The nurse has asked the client to dangle the arm off the bed and move it. 4 The nurse asks the client to move the arm with the other hand. 5 The nurse has asked the client to move the arm on the bed.

a,c,e (Rationale Flaccid paralysis is an expected finding during spinal shock. The client will develop spastic movements later as edema from the initial injury resolves. Complete loss of sensation is common during spinal shock. This loss occurs because of edema in the area of the injury. Some sensation may return as the edema resolves. Low blood pressure occurs during spinal shock caused by lack of vasoconstriction needed to maintain blood pressure. This lack occurs because of damage to the nerve supply to the peripheral blood vessels. Incontinence occurs because of damage to the nerves that supply the bladder. This may or may not be​ permanent, depending on the extent of the damage. Spinal shock causes an inability to regulate body temperature. The​ client's body will assume a temperature similar to the temperature of the environment. The​ client's skin would not be warm and flushed because of poor perfusion and low blood pressure during spinal shock.)

A nurse in the emergency department is admitting a client who was in a motor vehicle collision. The nurse is concerned that the client has a spinal cord injury with spinal shock when the nurse makes which assessment​ findings? ​(Select all that​ apply.) a Flaccid paralysis ​b Warm, flushed skin c Complete loss of sensation d Hypertension e Urinary incontinence

d (Rationale Dextrose​ 5% and​ 0.45% normal saline is a hypertonic solution that pulls water into the intravascular spaces and maintains blood pressure. Treatment is focused on treating the hypotension that a client with a spinal cord injury is likely experiencing.The​ 5% dextrose provides a very limited number of calories. This intravenous fluid does not provide sufficient calories for healing.The​ 0.45% saline provides only a limited amount of sodium and chloride. This solution does not provide such other electrolytes as potassium and calcium.Dextrose​ 5% and​ 0.45% normal saline pulls water from the cells and into the intravascular space. This is a hypertonic solution. A hypotonic solution such as​ 0.45% normal saline would allow water to enter the cells.)

A nurse in the emergency department is providing care for a client admitted with spinal cord injury. The health care provider has written an order for intravenous​ fluid, dextrose​ 5% and​ 0.45% normal saline. What is the purpose of this intravenous​ fluid? a This intravenous fluid provides necessary electrolytes. b This intravenous fluid provides water to hydrate the cells. c This intravenous fluid will provide calories to help with healing. d This intravenous fluid provides fluid volume and helps maintain blood pressure.

4 ( The nurse should clarify the order for muscle relaxants, the client will not experience muscle spasms until after the spinal shock is resolved. making muscle relaxants unnecessary at this time. Glucocorticoids decrease edema of the spinal cord. Plasma expanders treat hypotension caused by the SCI. H2 antagonists to decrease the complication of developing a gastric ulcer from the stress.)

A nurse is caring for a client who experienced a cervical spine injury 24 hrs ago. Which of the following types of prescribed medications should the nurse clarify with the provider? 1. glucocorticoids 2. plasma expanders 3. H2 antagonists 4. Muscle relaxants

1 (The nurse should implement the noninvasive use of a condom cath because the bladder will empty on its own due to the client having an upper motor neuron injury which is manifested by a spastic bladder The Credes method is for a client who has a flaccid bladder. The intermittent cath is for flaccid bladder, and indwelling cath is an invasive procedure)

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. The nurse should plan to implement which of the following types of bladder management methods? 1 condom catheter 2. intermittent urinary cath 3. credes method 4. indwelling cath

4 (ABC priority. Respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of vent support as needed is the priority. The nurse should monitor for the other options, but the greatest priority is respiratory compromise)

A nurse is caring for a client who has a C4 spinal cord injury. The nurse should recognize the client is at greatest risk for which of the following comlications? 1. Neurogenic shock 2. Paralytic ileus 3. Stress ulcer 4. Respiratory compromise

2 ( The greatest risk to the client is experiencing a CVA secondary to elevated BP caused by autonomic dysreflexia, the first action the nurse should take is to elevate the HOB until the client is in an upright position, which should lower the BP secondary to postural hypotension. all the other answers are things the nurse should do but not first)

A nurse is caring for a client who has a spinal cord injury who reports a severe headache and is sweating profusely. VS include BP 220/110 and apical HR 54 Which of the following actions should the nurse take first? 1. Notify the HCP 2. Sit the client upright in bed 3. Check the urinary cath for blockage 4 Admin the antihypertensive med

1 ( The greatest ri9sk to the client during the acute phase of an SCI is further damage to the spinal cord. When planning care, the priority intervention the nurse should take is to prevent further damage to the spinal cord by administration of corticosteroids, minimizing movements of the client until the spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.)

A nurse is planning care for a client who has a SCI involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel or bladder. which of the following is the nurses highest priority? 1. Prevention of further damage to the spinal cord 2. Prevention of contractures of the LE 3. Prevention of skin breakdown of areas that lack sensation 4. Prevention of postural hypotension when placing the client in a wheelchair

a,c,d (Rationale When providing education to a client about ways to avoid autonomic​ dysreflexia, the client needs to consume a​ high- fiber diet with adequate fluid to prevent constipation. The client also needs to monitor urine for color and odor. If the client experiences manifestations of a urinary tract​ infection, it must be treated immediately. The client needs to be instructed to wear​ loose-fitting clothes and to change positions frequently when sitting in the chair or when in bed. A client with a spinal cord injury should also avoid sunburn because it can lead to autonomic dysreflexia.)

A nurse is providing education to a client with a spinal cord injury. What information should the nurse provide to help the client avoid autonomic​ dysreflexia? ​(Select all that​ apply.) a Avoid excessive exposure to the sun b Consume a​ low-fiber diet c Change positions frequently when sitting in a chair d Monitor urine for color and odor e Wear​ tight-fitting clothes

b (ationale: The client with halo traction cannot drive because the traction limits mobility and impairs range of vision. The client should drink with a straw and cut foods into small pieces to facilitate chewing. The halo can cause imbalance, so the client is cautioned to monitor balance carefully. The client is taught to care for the skin under the vest. )

A nurse is teaching a client with a spinal cord injury who is being discharged with halo traction. The nurse concludes that further teaching is necessary upon learning that the client intends to: a Monitor balance carefully. b Drive in the daytime only. c Drink with a straw. d Care for the skin under the vest daily.

3 (It is a vasoconstrictive problem produced by excessive sympathetic nervous system stimulation. Autonomic dysreflexia is not a parasympathetic condition. )

A nurse manager is explaining autonomic dysreflexia to a nurse who has recently transferred to the ICU. Which statement would the manager evaluate as indicating this nurse has a good understanding of this disorder? 1 It is a cardiovascular problem produced by decreased cardiac output secondary to bradycardia. 2 It is a parasympathetic nervous system problem resulting from unopposed vasodilation. 3 It is a vasoconstrictive problem produced by excessive sympathetic nervous system stimulation. 4 It is a spastic disorder that limits mobility.

2 (The woman with SCI can participate in sexual activity but might not experience orgasm. Cessation in the nerve pathway may occur in spinal cord injury, but this does not negate the clients mental and emotional needs to creatively participate with their partner in a sexual relationship to reach orgasm. An indwelling urinary cath may be left in place during intercourse and need not be removed because the indwelling cath is placed in the urethra which is not the channel used for sex There are no contraindications, such as HTN to sexual activity in a woman with SCI.. SEx is allowed and HTN should be manageable. Because the spinal cord injury does not affect fertility, the client should have access to family planning info)

As a first step in teaching a woman with a SCI and quadriplegia about her sexual health, the nurse assesses her understanding of her current sexual functioning. Which statement by the client indicates she understands her current ability? 1. I will not be able to have sexual intercourse until the urinary cath is removed 2. I can participate in sexual activity but might not experience orgasm 3, I cannot have sexual intercourse because it causes hypertension but other sexual activity is okay 4. I should be able to participate in sexual activity but I will be infertile

d (Mrs. Gerry has​ hypotension, bradycardia, and low body​ temperature; is​ incontinent; and has no sensation below the injury. These are all symptoms of spinal shock. Homer syndrome is an incomplete cord transection of the cervical sympathetic nerves. An incomplete transection of the spinal cord leads to multiple​ manifestations, but the manifestations are different from those experienced with spinal shock. A complete transection of the spinal cord results in loss of motor and sensory function below the level of injury.)

Mrs. Gerry was involved in a motor vehicle crash 2 days ago and was admitted to the hospital for multiple​ injuries, including a broken right arm and fractures of L4 and L5. She has no sensation in her legs and is incontinent of bowel and bladder. Her temperature is​ labile, ranging from​ 98.0° to​ 96.9°F (36.7° to​ 37.2°C) over the past 18 hours. Her heart rate is 58​ beats/min, and her blood pressure is​ 96/60 mmHg. Her respirations are 22​ breaths/min. What condition do you anticipate Mrs. Gerry is​ experiencing? a Homer syndrome b Complete transection of the spinal cord c Incomplete transection of the spinal cord d Spinal shock

3 (long bone demineralization is a serious consequence of the loss of weight bearing. An excessive Ca load is brought to the kidneys, and precipitation may occur, predisposing to stone formation. Excessive intake of dairy products may promote constipation. However this is not the most accurate reason for decreasing Ca intake. Immobility does not increase Ca absorption from the intestine. Dairy products do not necessarily promote weight gain)

The client with a spinal cord injury asks the nurse why the dietician has recommended to decrease the total daily intake of Ca. Which response by the nurse would provide the most accurate information? 1. excessive intake of dairy products makes constipation more common 2. Immobility increases Ca absorption from the intestine 3. Lack of weight bearing causes demineralization of the long bones 4. Dairy products will likely contribute to weight gain

3 (The nurse must maintain a patent airway. WRong: #1 The nurse should stabilize the clients neck prior to removal from the car #2 The nurse must stabilize the neck before doing any assessments. Most nurses dont carry penlights and the clients pupil reaction can be determined after stabilization. #4 shaking the client could cause further damage, possibly leading to paralysis)

The nurse arrives at the site of a one care MVA and stops to render aid. The driver of the car is unconscious. After stabilizing the clients cervical spine, which action should the nurse do next? 1. Carefully remove the driver from the car 2. assess the clients pupils for reaction 3. assess the clients airway 4. attempt to wake the client up by shaking him

1,3,5 (O2 is administered initially to prevent hypoxemia, which can worsen the spinal cord injury. Therefore the nurse should determine how much O2 is reaching the periphery. Breathing exercises are supervised by the nurse to increase the strength and endurance of inspiratory muscles, especially those of the diaphragm. Corticosteroids are administered to decrease edema, and help prevent edema from ascending up the spinal cord causing breathing difficulties. WRONG #2 A C6 injury would not affect the clients ability to chew and swallow so pureed food is not necessary. #4 autonomic dsyreflexia occurs during the rehab phase not the acute phase.)

The nurse for the neuro ICU is caring for a client with a new Cervical SCI who is breathing independently. Which nursing interventions should be implemented? SATA 1.. Monitor the puse ox reading 2. Provide pureed foods 6 times a day 3. Encourage coughing and deep breathing 4. Assess for autonomic dysreflexia 5.. Admin Iv corticosteroids

a (Rationale: The nurse would want to observe pin sites for redness, edema, and drainage, and would want to assure that the vest fits snugly. Following the nursing process, data collection would precede implementation of the actions in the other choices. )

The nurse is caring for a client recently placed in a halo brace because of a spinal cord injury. What is the first priority of the nurse? a Examine the pin sites. b Encourage active range of motion to lower extremities. c Loosen connections on the vest to observe the skin. d Ask how the client is able to reposition in bed.

c (Rationale: An injury to the sacral spine at S2-S4 is likely to cause the male client to have erectile and ejaculation issues. Cervical spine injuries are fatal at C2-C4 and cause paralysis below C4. Thoracic injury symptoms range from loss of chest movement to loss of movement of bowel and bladder. Lumbar injuries can cause issues with movement and sensation of the lower extremities. )

The nurse is caring for a client who fell from a two-story roof 2 days ago. The client states that he is experiencing erectile dysfunction. The nurse suspects that this client is experiencing: a A lumbar spine injury b A cervical spine injury c A sacral injury at the level of S3 d A thoracic injury at the level of T6

b (Rationale: The client who is taking in inadequate food is at risk for developing breaks in the skin and resulting infection. Headaches and contractures are not associated with poor nutrition. Constipation, not diarrhea, is a risk associated with decreased fluids. )

The nurse plans to instruct the client with a spinal cord injury about risks associated with inadequate intake of food and fluids including: a Contractures of the legs b Skin breakdown c Diarrhea d Headaches

a,c,e (Rationale: In order to prevent injury, the nurse removes potentially harmful objects near the legs, performs range of motion to prevent contractures, and provides skin care to prevent skin injuries. Restraints have the potential to cause injury during spastic episodes. Baclofen (Lioresal) is usually ordered PRN and is given for increased spasticity. )

The nurse selects the nursing diagnosis of risk for injury related to spasticity of the leg muscles for a client with a spinal cord injury with paraplegia. The nurse plans which interventions? (Select all that apply.) a Remove potentially harmful objects near the spastic legs. b Do not give baclofen (Lioresal) unless client seizes. c Perform range of motion to the legs. d Use padded restraints to immobilize the limbs. e Provide skin care to the affected limbs.

a (Rationale: The nurse would have a Stryker bed available for the client with Crutchfield tongs. The nurse never removes weights applied to Crutchfield tongs. The nurse is able to evaluate that the weights are hanging free and that the amount of weights ordered has been correctly applied)

The nurse will be caring for a client with a spinal cord injury who has been placed in Crutchfield tongs. The nurse plans what intervention for the client? a Using a Stryker frame bed b Leaving assessment of the weights to the physician c Calling the physician to determine if the traction is appropriate d Removing the weights during repositioning

2 (DVT is a potential complication of immobility, which can occur because the client canot move the LE. as a result of the L1 SCI. Low does anticoags help prevent DVT Wrong: #1 O2 is administered initially to maintain a high arterial partial pressure of oxygen PaO2. because hypoxemia can worsen a neurological deficit to the spine initially but this client is in rehab and thus not in the initial stages of injury. #3 This client needs passive ROM #4 A client with injury to C4 or above would be ventilator dependent. )

The rehab nurse is caring for the client with a Lumbar1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep o2 via nc on at all times 2. Admin low dose SC anticoagulants 3. Perform active lower ROM 4. Refer to a speech therapist for ventilator assisted speech

3 (The priority concern is to immobilize the head and neck to prevent further trauma when a fractured vertebra is unstable and easily displaced. Although wrapping and supporting the etremities is important, it does not take priority over immobilizing the head and neck. Pain usually is not a significant consideration with this type of injury. The neck should be kept in a neutral position and immobilized. Flexion of the neck is avoided. )

When planning to move a person with a possible SCI, the nurse should direct the team to: 1 limit movement of the arms by wrapping them next to the body 2. move the person gently to help reduce pain 3 immobilize the head and neck to prevent further injury 4. cushion the back with pillows to ensure comfort

a (Rationale Excessive force in which the neck is forced backwards is hyperextension and is seen in whiplash injuries.Hyperflexion occurs when excessive force forces the head forward onto the chest.Transection of the spinal cord occurs when a force partially or completely severs the spinal cord.Compression occurs when excessive vertical force is applied to the spinal cord.)

When reviewing the medical record of a client who experienced a spinal cord​ injury, the nurse notes that the client suffered a whiplash injury. What type of excessive force was placed on the vertebral​ column? a Hyperextension b Transection of the spinal cord c Compression d Hyperflexion

d (Rationale The client is suffering from Homer​ syndrome, which results from an incomplete cord transection of the cervical sympathetic nerves. ​Brown-S​équard syndrome results from penetrating trauma to the spinal cord causing hemisection of either the anterior or posterior spinal cord. Central cord syndrome results from cervical cord transection or hyperextension. Posterior syndrome results from compression of the spinal root.)

When reviewing the medical​ record, the nurse notes that the client experienced an incomplete cord transection of the cervical sympathetic nerves. What type of incomplete spinal cord injury did the client​ suffer? a Posterior syndrome ​b Brown-S​équard syndrome c Central cord syndrome d Homer syndrome

2,4 (Removing the vest for daily hygiene and bathing Using the vest's struts to help pull the client up in bed The client in a halo device can and should be turned. Pulling on the vest struts may disrupt the position of the client's head and neck.)

Which interventions are contraindicated in the care of a client in a halo vest? Select all that apply. 1 Turning the client every 2 hours 2 Removing the vest for daily hygiene and bathing 3 Providing pin care as per unit protocol 4 Using the vest's struts to help pull the client up in bed 5 Inspecting the pins for security

a,e (Preventing complications and improving the client's ability to perform​ self-care activities occur in the recovery phase of nursing care for a client with a SCI. Maintaining​ immobilization; maintaining an adequate​ airway; and preventing movement that could cause more damage are immediate nursing care measures for the client with a SCI.)

Which nursing intervention is included in the recovery phase of a client with a spinal cord injury​ (SCI)? ​(Select all that​ apply.) a Preventing complications b Maintaining an adequate airway c Preventing movement that could cause more damage d Maintaining immobilization e Improving the client​'s ability to perform​ self-care activities

3 (The nurse is responsible for training but the UAP can position)

Which nursing task would be most appropriate for the nurse to delegate to the UAP? 1. Teach Credes manevuer to the client needing to void 2 Admin the tube feeding to the client who is quadriplegic 3. Assist with the bowel training by placing the client on the bedside commode 4. Observe the client demonstrating self cath technique

2 (A supine position with the clients legs flexed is the most comfortable position because is allows for the disc to recess of the nerve, thus alleviating the pressure and pain. The prone position causes hyperextension of the spine and increased pressure of the disc on the nerve root on the right. A ruptured disc at L5-S1 right identifies a ruptured disc compressing the R nerve root exiting the L5-S1 spinous process; terms such as this are commonly used in the analysis of MRI, myelogram or Hx and Px exam. If the ruptured area of the disc were in the central area of the spinous process, the prone position and hyperextension might relieve the disc pressure on the nerve. A high Fowlers or sitting position increases the pressure of the disc on the nerve root because of gravity as does the SIMS)

Which position would be most comfortable to a client with a ruptured disc at L5-S1 right? 1. prone 2. supine with the legs flexed 3. high Fowlers 4. right Sims

a,b,c,d (When planning care for a client with a spinal cord​ injury, the nurse needs to include the following​ problems: Impaired breathing​ patterns, impaired urinary​ function, self-care​ deficits, and risk of emotional trauma. Acute pain is not typically a problem for a spinal cord injury client.)

Which problem should be included in the plan of care for a client with a spinal cord​ injury? ​(Select all that​ apply.) a Impaired urinary function ​b Self-care deficits c Impaired breathing patterns d Risk of emotional trauma e Acute pain

d (A bladder infection can trigger autonomic dysreflexia.​ Bradycardia; warm, flushed​ skin; and hypertension are all​ manifestations, not​ triggers, of autonomic dysreflexia.)

Which disorder can trigger autonomic​ dysreflexia? a Hypertension ​b Warm, flushed skin c Bradycardia d Bladder infection

1 (The client with dyspnea and rr of 12 has S/s of complication and should be assessed first because ascending paralysis at the C-6 level could cause the client to stop breathing. WRONG #3 The client with a lower SCI would not be at risk for autonomic dyreflexia, therefore a complaint of a headache and feeling hot would not be priority over a airway problem.)

10 Which client should the nurse assess first after receiving the change of shift report? 1. The client with a C-6 SCI who is complaining of dyspnea and has a RR of 12 2 The client with a L-4 SCI who is frightened about being transferred to the rehab unit 3. The client with a L-2 SCI who is complaining of a headache and feeling hot all of a sudden 4. The client with a C-4 SCI who is on a ventilator and has pulse ox reading of 98%

2 (The client with a C-6 SCI is expected to have autonomic dysreflexia but it is an emergency situation, therefore the nurse should assess this client first.)

3 The nurse has just received the shift report. Which client should the nurse assess first? 1. The client with Guillain-Barre syndrome who has ascending paralysis to the knees 2 The client with a C6 spinal cord injury who has autonomic dysreflexia 3. The client with Parkinsons disease who is experiencing pill rolling 4. The client with Huntingtons disease who is writhing, twisting movements of the face

3 (Airway first. You dont move the client unless in danger present. )

30 The nurse is the first person on scene of an MVA. The driver is in the drivers seat unconscious. What action should the nurse implement first? 1. stabilize the drivers cervical spine 2. Do not move the client from the accident 3. Ensure the driver has a patent airway 4. Control external bleeding

1 (Therapeutic communication addresses the clients feelings and attempts to allow the client to verbalize those feelings. The client is grieving over her loss, and the nurse should let her vent)

40 The HH nurse is caring for a 22 y/o F client who sustained an L-5 SCI 2 months ago, The client says "I will never be happy again. I cant walk, I cant drive, and I had to quit college" Which intervention should the nurse implement first? 1. Allow the client to ventilate her feelings of hopelessness 2 Refer the client to the HH agency social worker 3. Recommend contacting the American Spinal Cord Asociation 4. Ask the client whether she has any friends who come and visit

1 (The clients ability to maneuver the wheelchair indicates the client is progressing in therapy. WRong #2 This statement indicates the client is in denial. #3 Eye blinks are used with a higher level injury #4 The building of the ramp indicates the husband is preparing, not the clients progress)

55 The nurse in a rehab facility is evaluating the progress of a F client who sustained a C-6 C-7 SCI. Which outcome indicates the client is improving? 1 The client can maneuver the automatic wheelchair into the hallway 2. The client states she will be able to return to work in a few weeks 3. The client uses eye blinks to communicate yes and no responses 4. The clients husband built a wheelchair ramp onto their home

3 (pulling the client up under the arm can cause shoulder displacement. A belt around the waist should be used to move the client. Passive ROM can prevent contractures and atrophy Rasising the foot of the bed assists in venous return to reduce edema. High top tennis shoes help prevent foot drop)

A UAP is providing care to a client with L sided paralysis. Which action by the UAP requires the nurse to provide further instruction? 1. Providing passive ROM to the L extremities during the bed bath 2. elevating the foot of the bed to reduce edema 3 pulling up the client under the L shoulder when getting the cliet out of bed to a chair 4. putting high top tennis shoes on the client after bathing

2 (MRI The MRI is used to identify damage to the spinal cord, ligaments, and discs.)

A client has a suspected ligament injury to the spinal vertebrae. The nurse would prepare this client for which diagnostic test? 1 Somatosensory-evoked potentials (SEPs) 2 MRI 3 Lateral x-ray 4 CT scan

c (Rationale After a spinal cord​ injury, the spinal cord will swell and stay swollen for several days. This swelling will extend up and down the spinal cord for up to two segments. The swelling will affect nerve​ transmission, including the phrenic nerve. This damage can affect respirations.Hemorrhage will cause further damage to the spinal cord.​ However, the nerve transmission is to the diaphragm rather than the lungs.Bone fragments from fractured vertebrae may migrate.​ However, the risk of respiratory depression comes from damage to the area that supplies the phrenic nerve. The phrenic nerve supplies the diaphragm.The client will be at risk of aspiration caused by immobility and impaired swallowing from the injury. The spinal cord does not put pressure on the esophagus.)

A client is admitted to the intensive care unit with an injury in the cervical region of the spinal cord. Why must the nurse monitor the client​'s respiratory​ function? a The client is at high risk of aspiration caused by pressure on the esophagus from the spinal cord injury. b Hemorrhage in the spinal cord will interfere with nerve transmission to the lungs. c The spinal cord will swell and affect the nerves that maintain respiratory function. d Bone fragments from the damaged vertebrae can lodge in the trachea and bronchi.

4 (Your Answer: Hyperflexion Hyperflexion injury is most often a result of sudden deceleration of the motion of the head, as in a head-on collision. This results in anterior vertebrae dislocation, posterior ligament tearing, and cord compression.)

A client is brought to the Emergency Department after being injured in a head-on car accident. The nurse would be most concerned about which kind of spinal cord injury? 1 Hyperextension 2 Axial loading 3 Rotational 4 Hyperflexion

4 (The client's injury includes disruption of two or more of the spinal columns and close attention must be paid to decrease the chance of secondary injury. The spine consists of three columns. An unstable spinal injury diagnosis is made when two or more of those columns are disrupted. Secondary injury is a high risk of unstable spinal injury.)

A client is brought to the Emergency Department after sustaining a spinal injury in a boating accident. The diagnosis of unstable spinal injury is made. How should the nurse interpret this information? 1 The client will have a maximal degree of sensory impairment. 2 Total flaccid paralysis is the determining factor for making this diagnosis. 3 This diagnosis is not made unless there are associated hemodynamic changes the nurse will need to manage. 4 The client's injury includes disruption of two or more of the spinal columns and close attention must be paid to decrease the chance of secondary injury.

1 (There is not enough information to determine this parameter. ASIA-C could be the correct classification but this is not the best answer. )

A client is brought to the Emergency Department with a C5-6 fracture involving the posterior wall of the vertebral body and bilateral lamina. During assessment, the nurse notes the client can feel touch on the toes. Which ASIA impairment scale designation best reflects this injury? 1 There is not enough information to determine this parameter. 2 ASIA-C 3 ASIA-A 4 ASIA-B

2 (based on the clients comments, the nurse should call the surgeon to verify the location of the surgery The clients comments indicate radiculopathy of L4-L5, but the informed consent form states L3-L4. Radiculopathy of L3-L4 involves pain radiating from the back of the buttocks to the posterior thigh to the inner calf. the nurse must act as a client advocate and not ask the client to sign the consent until the correct procedure is identified and confirmed on the consent. The nurse has no legal authority or responsibility to change the consent. The Hx is a source of info, but when the client is coherent and the Hx is contradictory, the HCP should be contacted to clarify the situation. Ultimately it is the surgeons responsibility to identify the site of surgery specified on the consent form)

A client tells the nurse about having numbness from the back of the L buttock to the dorsum of the foot and big toe. The client is scheduled for a laminectomy, and the operative consent form states "a left lumbar laminectomy of L3-L4" What should the nurse do next? 1. Have the client sign the consent form 2. Call the surgeon 3. Change the consent form 4. Review the client HX

3 (grief is a process that takes time)

A client with a SCI who has been active in sports and outdoor activities talks almost obsessively about his past activities. In tears one day he asks the nurse "Why am I unable to stop talking about these things? I know those days are gone forever." Which response by the nurse conveys the best understanding of the clients behavior? 1. Be patient it takes time to adjust to such a massive loss 2. Talking about the past is a form of denial. We have to help you focus on today 3. Reviewing your losses is a way to help you work through your grief and loss 4. It is a simple escape mechanism to go back and live in happier times

a (Rationale Methylprednisone in large doses is given to decrease inflammation and reduce damage to surrounding nerve cells.The acute pain of traumatic injury is treated with opioids. Heparin and Coumadin are given to prevent DVT and pulmonary embolism. Muscle relaxants are given for muscle spasticity.)

A client with a spinal cord injury is scheduled to receive a high dose of methylprednisone. The nurse recognizes that this medication is being administered for which of the following ​reasons? a To decrease inflammation and reduce damage to surrounding nerve cells b To treat the acute pain of the traumatic injury c To reduce muscle spasticity d To prevent deep vein thrombosis​ (DVT) and pulmonary embolism

4 (The client's stools are positive for blood. Steroid use does not affect urine specific gravity. )

A client with an SCI is receiving methylprednisolone. Which finding would the nurse interpret as indicating a possible complication of this therapy? 1 The client complains of a metallic taste. 2 The client's urine specific gravity is increased. 3 The client reports seeing halos around lights. 4 The client's stools are positive for blood.

2 (Brown-Sequard syndrome Brown-Sequard syndrome results from incomplete spinal cord injury.)

A nurse is applying for a position at a facility where care is provided to clients who have incomplete spinal cord injuries. The nurse can expect to care for clients with which condition? 1 Paraplegia 2 Brown-Sequard syndrome 3 Tetraplegia 4 Quadriplegia

4 (The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic; owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place or that the client will walk again. The movement is not voluntary and cannot be brought under voluntary control)

After 1 month of therapy the client in spinal shock begins to experience muscle spasms in the legs and calls the nurse in excitement to report leg movement. Which response by the nurse would be the most accurate? 1. These movements indicate that the damaged nerves are healing 2. This is a good sign Keep trying to move the affected muscles 3. The return of movement means that eventually you should be able to walk again 4. The movements occur from the muscle reflexes that cannot be initiated or controlled by the brain

4 (ABC respiratory distress. The other have expected s/s)

CS # 9 Mr Leo is making shift assignments, which client should be assigned to the most experienced nurse? 1. The client dx with bacterial meningitis who is experiencing photophobia 2. The client with an L-4 SCI who has spastic muscle spasms of the LE 3. The client dx with Parkinsons who has a mask like face and pill rolling 4. The client with ALS who is having respiratory distress

3 (during the period of spinal shock the bladder is completely atonic and will continue to fill passively unless the client is catheterized. The bladder will not go into spasms or cause uncontrolled urination. Bladder function will not be normal during the period of spinal shock)

During the period of spinal shock, the nurse should expect the clients bladder function to be : 1 spastic 2. normal 3 atonic 4. uncontrolled

2 (ondansetron is a selective serotonin receptor antagonist that acts centrally to control the clients N in the post op phase )

Immed after a lumbar laminectomy, the nurse administers ondansetron hydrochloride to the client as prescribed. The nurse determines that the drug is effective when which sign is controlled? 1 muscle spasms 2. nausea 3. shivering 4 dry mouth

4 (other signs wont be available. Can check with doppler but girth is the first way to notice)

Which is the best method to assess for the development of DVT in a client with a SCI? 1. Homans sign 2 pain 3. tenderness 4. leg girth

1 (Autonomic dysreflexia Autonomic dysreflexia is caused by sympathetic nervous system stimulation and is an emergency. Hypertension, headache, flushed face, and nasal stuffiness are all symptoms of AD)

Last week a client sustained a gunshot wound that caused a T2 SCI. This morning the client has a B/P of 210/108 and a flushed face, and complains of nasal stuffiness and a headache. The nurse responds to this assessment rapidly because of the potential for it to indicate which disorder? 1 Autonomic dysreflexia 2 Essential hypertension 3 Pneumonia onset 4 Neurogenic shock

b

Mr. Lin has been hospitalized for 23 days and has been in a rehabilitation hospital for an additional 10 days after a motor vehicle crash left him with partial paralysis in both legs. He has sensation but not movement. The nurse is preparing him for discharge home. He is able to perform most​ self-care activities and can get to and from the wheelchair with assistance. Which statement by Mr. Lin makes the nurse aware of the need for a home health​ referral? ​a "I can't wait to eat home cooking​ again." ​b "I can wait until my wife is home from work to help me go to the​ bathroom." ​c "My wife can leave things on the counter for me to​ reach." d ​"My wheelchair will fit through the bathroom door but not the laundry room​ door."

2 (The rehab commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury. WRONG:#! The ASIA is an appropriate referral for living with this condition, but does not help find employment. #3 the client is not asking about disability, he is concerned with employment. )

The 34 yo male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged. Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Association 2. Refer the client to the state rehab commission 3. Ask the social worker about applying for disability 4. Suggest that the client talk with his sig other about this concern

1 (therapeutic communication addresses the clients feelings and attempts to allow the client to verbalize feelings)

The HH nurse is caring for a 28 yo client with a T10 SCI who says "I cant do anything, Why am I so worthless?" which statement by the nurse would be the most therapeutic? 1. This must be very hard for you. You're feeling worthless? 2. You shouldnt feel worthless, you are still alive 3 Why do you feel worthless? you still have the use of your arms 4. If you attended a work rehab program you wouldnt feel worthless

4 (The first 2 weeks after an SCI above T7 the BP tends to be unstable and low, slight elevations of the HOB can cause profound hypotension, therefore the nurse should lower the HOB immed)

The ICU nurse is caring fro a client with a T1 SCI. When the nurse elevates the HOB 30 degrees, the client complains of light headedness, and dizziness. The clients VS are T99.2 P 98 R 24 and BP 84/40 Which action should the nurse implement? 1 Notify the HCP ASAP 2. Calm the client down by talking therapeutically 3 Increase the IV rate by 50 mL/hr 4 Lower the HOB immed

d ( Feedback Rationale: The nurse helps the family to understand and acknowledge the client's anger. The family would then make the choice about whether or not to continue to participate in the client's care. Asking the client to stop the anger is not reasonable. The client is grieving a significant loss and needs to be allowed to work through the issues. Telling the client that the family will not visit is threatening and inappropriate. )

The family members of a client with a spinal cord injury tell the nurse that the client becomes angry when family members try to help the client. The nurse's best response is to: a Tell the client the family will not visit anymore. b Ask the family to refrain from giving care. c Ask the client to stop acting out with the family. d Assist the family to understand the source of the client's anger.

3 (The client is experiencing autonomic dysreflexia. Which is a medical emergency. The nurse should immed evaluate the client for bladder distention and be prepared to cath the client. Positioning the client on the L side, reducing environmental stimuli, and administering pain meds are not used to treat autonomic hyperreflexia.)

The nurse is caring for a client with a spinal cord injury. The client is experiencing blurred vision and has a BP of 204/102 What should the nurse do first? 1. position the client on the L side 2. control the environment by turning the lights off and decreasing stimulation for the client 3. Check the clients bladder for distention 4. Admin the pain meds

1 (ABC )

The nurse is caring for clients on the rehab unit. Which clients should the nurse assess first after receiving the change of shift report? 1 The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs 2. The client with an L4 SCI who is crying and very upset about being discharged home 3 The client with an L2 SCI who is complaining of a headache and feeling very hot 4 The client with a T4 SCI who is unable to move the LE

d (Magnetic evoked potentials measure nerve conduction along pathways to evaluate muscle response. MRIs and CTs are used to determine the level of the spinal cord that is​ damaged, not to measure nerve conduction. Spinal​ x-rays identify fractured​ vertebrae; they do not measure nerve conduction.)

Which diagnostic test measures nerve conduction along pathways to evaluate muscle​ response? a MRI of the spine b Spinal​ x-rays c CT of the spine d Magnetic evoked potentials

a,b,d (Rationale Decompression surgery for SCI is performed for clients with progressive neurologic​ deterioration, facet​ dislocation, spinal nerve​ compression, and extradural lesions. Spinal stabilization is done to realign the spine in spinal fractures. Cervical fractures without major cord damage are treated with cervical traction devices like​ Gardner-Wells tongs and halo external fixation devices.)

The nurse is preparing a presentation for a trauma symposium. When discussing clients with spinal cord injury​ (SCI), which condition is an indication for decompression​ surgery? ​(Select all that​ apply.) a Spinal nerve compression b Progressive neurological deterioration c Spinal stabilization d Facet dislocation e Cervical fractures without major cord damage

3 (This client has a SCI of the sacral region of the spinal cord and will have bladder and bowel dysfunction, as well as loss of sensation and muscle control below the injury. The other options are true of a client who has quadriplegia)

The nurse is taking care of a client with a SCI. The extent of the clients injury is shown below (imagine a man shaded from Hips down). Which finding is expected when assessing this client? 1. inability to move the arms 2. loss of sensation in the hands and fingers 3. dysfunction of bowel and bladder 4. difficulty breathing.

1 (The client with a spinal cord transect above T5 is least likely to develop diarrhea. Rather constipation due to atonia would be possible. The client is at risk for development of paralytic ileus because the sympathetic nerve innervation to the vagus nerve which dominates all the vessels and organs below T5 (eg the intestinal tract) has been disrupted and therefore so has movement or peristalsis. The client is at risk for development of stress ulcers because the sympathetic nerve innervation to the stomach has been disrupted which results in excessive release of hydrochloric acid in the stomach. Allowing contact of the hydrochloric acid with stomach mucosa. The client does not feel subjective signs of stress ulcers (pain guarding, tenderness) and therefore is at increased risk for bleeding because complications of an ulcer can develop before early Dx)

When assessing a client with a cord transection above T5 for possible complications, which complication is least likely to occur? 1 diarrhea 2. paralytic ileus 3. stress ulcers 4. intra abdominal bleeding

b,c,e (Rationale The client is experiencing a lumbar spinal cord​ injury, which affects the lower​ limbs, back and abdomen. When planning care for this​ client, the nurse needs to identify the following​ problems: impaired urinary​ elimination; diminished sensory​ perception; and​ self-care deficits. Since the injury does not affect the diaphragm and chest​ area, impaired breathing patterns and risk of aspiration do not apply to this client.)

When planning care for a client with a complete lumbar spinal cord​ injury, which problem should the nurse​ address? ​(Select all that​ apply.) a Impaired breathing patterns b Impaired urinary function c Diminished sensory perception d Risk of aspiration ​e Self-care deficits

2 (Although assessment of renal GI and biliary function is important, with the spinal cord transection at T4 the clients vascular status is the primary focus of the nursing assessment because the sympathetic feedback system is lost and the client is at risk for hypotension and bradycardia)

When the client has a cord transection at T4, the nurse should focus the assessment on: 1. renal status 2. vascular status 3 GI function 4. biliary function

d (Excessive rotation involves the head turning excessively to the left or right. Hyperflexion occurs when the neck is forced​ forward, not to the left or right. Hyperextension occurs when the neck is forced​ backward, not to the left or right. Axial loading involves​ compression, not turning of the head or neck.)

Which mechanism causing spinal cord injury is characterized by the head turned sharply to the left or​ right? a Hyperextension b Axial loading c Hyperflexion d Excessive rotation

1,2,4,5 ( All of the strategies except straight catheterization may stimulate voiding in clients with an SCI. Intermittent bladder catheterization can be used to empty the client's bladder, but it will not stimulate voiding. Focus: Prioritization)

12. You are helping a client with an SCI to establish a bladder retraining program. Which strategies may stimulate the client to void? (Select all that apply.) 1. Stroking the client's inner thigh 2. Pulling on the client's pubic hair 3. Initiating intermittent straight catheterization 4. Pouring warm water over the client's perineum 5. Tapping the bladder to stimulate the detrusor muscle

2 ( These signs and symptoms are characteristic of autonomic dysreflexia, a neurologic emergency that must be promptly treated to prevent a hypertensive stroke. The cause of this syndrome is noxious stimuli, most often a distended bladder or constipation, so checking for poor catheter drainage, bladder distention, and fecal impaction is the first action that should be taken. Adjusting the room temperature may be helpful, because too cool a temperature in the room may contribute to the problem. Acetaminophen will not decrease the autonomic dysreflexia that is causing the client's headache. Notifying the physician may be necessary if nursing actions do not resolve symptoms. Focus: Prioritization)

8. A client with a spinal cord injury (SCI) reports sudden severe throbbing headache that started a short time ago. Assessment of the client reveals increased blood pressure (168/94 mm Hg) and decreased heart rate (48 beats/min), diaphoresis, and flushing of the face and neck. What action should you take first? 1. Administer the ordered acetaminophen (Tylenol). 2. Check the Foley tubing for kinks or obstruction. 3. Adjust the temperature in the client's room. 4. Notify the physician about the change in status.

a (Rationale The client will benefit from being as independent as possible both at home and at school. The parents will need information about the size of doorways and other possible barriers to independence in the home. Because of the​ client's stage of​ development, the nurse must be careful about making referrals and suggestions about a group home. The client will have some level of dependence at home.​ However, the nurse would explore options with the client and her parents before making this type of suggestion. Home schooling would isolate the client from her friends. The client would benefit socially from interacting with other teenagers. Attending school will facilitate socialization. With proper​ care, the client can lead a productive life. By this​ point, the parents are well aware of the impact of a cervical spinal cord injury. The nurse would not provide information that would diminish hope for a productive life.)

A nurse on the inpatient rehabilitation unit is preparing a​ 15-year-old female client with cervical spinal cord injury for discharge to home with her parents. What intervention should the nurse provide to facilitate this client​'s ​discharge? a Discuss ways to make the home environment accessible b Provide information about group home options c Provide information about home schooling d Discuss the client​'s prognosis and expected life span with the parents

a,b,e (Rationale The client has manifestations of autonomic dysreflexia. This is a medical emergency. A distended urinary bladder can cause autonomic dysreflexia. If the bladder is causing the​ problem, the nurse can relieve manifestations by draining the​ client's bladder. A distended bowel can cause autonomic dysreflexia. If the bowel is the​ problem, the nurse can relieve the manifestations by removing the impaction. The compression stockings can contribute to autonomic dysreflexia by creating an irritation that causes the manifestations. The stockings also elevate blood pressure by increasing venous return to the heart. Rather than rechecking the blood pressure every 2​ hours, the nurse would continue to look for the cause until it is found and corrected. Administering acetaminophen would not address the manifestations of autonomic dysreflexia.)

A nurse on the​ medical-surgical unit is providing care for a client with cervical spinal cord injury from an accident several years ago. The client reports a headache. The​ client's blood pressure is​ 230/115 mmHg. What intervention should the nurse provide for this​ client? ​(Select all that​ apply.) a Remove the​ client's compression stockings b Check the client​'s bladder c Administer acetaminophen​ (Tylenol) d Recheck the blood pressure in 2 hours e Check the client for bowel impaction

2 (These s/s indicate spinal shock, therefore, this client should be assessed first and appropriate meds administered.)

CS#10 The nurse is caring for clients on a Neuro ICU. Which client should the nurse assess first? 1 The client with ICP whose Glasgow Coma Scale went from 11 to 14 2. The client dx with C-6 SCI who has bradycardia, hypotension, and hyperreflexia 3. The client with a brain stem herniation whose big toe moves toward the top surface of the foot and the other toes fan out after the sole of the foot has been firmly stroked 4. The client dx with WEst nile virus who has a temp of 101.2 and generalized body aches

4 (first palpate the bladder to determine if the client is experiencing autonomic dysreflexia. which is what should first be considered with the S/s. IF the clients bladder is full THEN the immed insert the urinary cath which will relieve the problem.)

CS#5 Jessie is caring for a client who had a C-6 SCI 2 years ago. and is admitted for Stage IV pressure ulcers in the coccyx area. The client is complaining of a severe headache and the BP is 190/110 Which interventions should Jesse implement first? 1 Insert a urinary cath 2. Complete a neurological assessment 3. Put the client in Trendelenburg position 4. Palpate the clients bladder

1 (put on the side to maintain airway. )

Cs #6 Mr leo is making rounds and he enters the room of a client having a seizure. Which priority intervention should Mr. Leo implement? 1.. Place the client on his side 2. Call the rapid response team 3. Determine if the client is incont of urine 4. Provide the client with privacy during the seizure

b (Anticoagulants​ (heparin, Coumadin) prevent DVT and pulmonary embolism. A proton pump inhibitor is used to prevent​ stress-related gastric ulcers in the client with a spinal cord disorder. Antispasmodics treat​ spasticity, not DVTs or pulmonary embolism. Vasopressors treat bradycardia and​ hypotension; they do not prevent DVTs or pulmonary embolism.)

Which type of medication is administered to the client with a spinal cord injury to prevent deep vein thrombosis​ (DVT) and pulmonary​ embolism? a Vasopressors b Anticoagulants c Proton pump inhibitors d Antispasmodics

1 (neurogenic shock associated with SCI represents a sudden depression of reflex activity below the level of injury. T12 is just above the waist therefore no reflex activity below the waist would be expected. WRong#2 assessment of the movement of the UE would be more appropriate with a higher level injury an injury in the cervical area might cause an inability to move the UE #3 complaints of a pounding headache are not typical of a T12 injury. #4 Hypotension, and tachycardia are signs of hypovolemic shock but these do not occur in spinal shock)

In assessing a client with a Thoracic SCI, which clinical manifestation would the nurse expect to find to support the Dx of neurogenic shock? 1. no reflex activity below the waist 2. inability to move the UE 3. Complaints of a pounding headache 4. Hypotension and tachycardia

a (The nurse would anticipate that the health care provider will order methylprednisolone​ (a corticosteroid) because the injury occurred just an hour​ ago, and the drug might help reduce the effect of the injury by decreasing edema and ischemia at the injury site. Although​ vasopressors, antiemetics, and antispasmodics might be​ ordered, there is no evidence that they are needed in this scenario. At this​ point, reducing swelling is critical to reducing the extent of injury.)

Mr. Casey is a​ 34-year-old construction worker who fell from a roof as he was installing shingles. He is being cared for in the emergency department. He sustained fractures at C5 and C6. He is intubated with cardiac​ monitoring, has an intravenous​ (IV) line in​ place, and his neck is immobilized. The accident occurred about 1 hour ago. The health care provider​ states, "We need to do something about the​ swelling." Which type of medication does the nurse anticipate the health care provider will​ order? a A corticosteroid b An antispasmodic c An antiemetic d A vasopressor

4

The client is dx with an SCI and is scheduled for MRI.. Which question would be most appropriate for the nurse to ask prior to taking the client to the diagnostic test? 1. Do you have trouble hearing? 2. Are you allergic to any type of dairy? 3 Have you eaten anything in the last 8 hrs? 4. Are you uncomfortable in tight spaces?

3 (This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with spinal cord injury above T6. The most common cause is a full bladder.)

The client with a C6 SCI is admitted to the ED complaining of severe pounding headache and has a BP of 180/110. Which intervention should the ED nurse implement? 1. Keep the client flat on the bed 2. Dim the lights 3. Assess for bladder distension 4. Admin narc analgesic

4

The client with a C6 spinal cord injury is crying and asks the nurse, :Why did I have to survive? I wish I was dead." Which statement is the nurses best response? 1 Dont talk like that. At least you are alive and able to talk 2. God must have something planned for your life Pray about it 3. You survived because the people at the accident saved your life 4. This must be difficult to cope with . Would you like to talk?

4 (an Iv line is not required for an MRI. If the client has an IV infusion it is usually SL for the transport and procedure. )

Which action would not be appropriate to include when preparing a client for MRI to evaluate a ruptured disc? 1. informing the client that the procedure is painless 2. taking a thorough Hx of past surgeries 3. checking for previous claustrophobia 4. starting an IV line at keep-open rate

4 ( The first priority for the client with an SCI is assessing respiratory patterns and ensuring an adequate airway. A client with a high cervical injury is at risk for respiratory compromise, because spinal nerves C3 through C5 innervate the phrenic nerve, which controls the diaphragm. The other assessments are also necessary but are not as high a priority. Focus: Prioritization)

10. A client with an SCI at level C3-C4 is being cared for in the emergency department (ED). What is the priority assessment? 1. Determine the level at which the client has intact sensation. 2. Assess the level at which the client has retained mobility. 3. Check blood pressure and pulse for signs of spinal shock. 4. Monitor respiratory effort and oxygen saturation level.

d (Spinal cord injury is a common cause of neurogenic shock. Hint #22 / 3 Neurogenic shock involves the interruption of sympathetic tone. Hint #33 / 3 Manifestations of sympathetic tone loss include warm, dry skin and bradycardia.)

After falling from a 10foot ladder, a patient is brought to the emergency department. The patient is alert, reports back pain, and difficulty moving the lower extremities. Which additional observation is an indication the patient may be experiencing neurogenic shock? Choose 1 answer: ACool and pale skin B Increased systolic blood pressure C Poor skin turgor D Bradycardia

3 (A 15 on the Glasgow Coma scale indicates the client is neurologically intact. and a 6 indicates the client is not neurologically intact, therefore see this client first. WRONG:#1 This client may be developing pneumonia and needs assessed but not prior to #3. )

CS #3 Courtney is caring for the following clients on the neurological ICU Which client should Courtney assess first? 1. The client with C-6 SCI who is complaining of dyspnea and has crackles 2. The client with Guillain Barre syndrome who is complaining of ascending paralysis 3. The client with TBI who has a Glasgow Coma scale score of 6 4. The client dx with CVA who has expressive dysphagia

2 (reddened areas especially under the brace must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period. You cant remove the pins they are in the skull! The vest liner should be changed for hygiene. Encourage the client to ambulate to prevent complications of immobility)

The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins 2 Instruct the client to report reddened or irritated skin areas 3. Inform the client that the vest liner cannot be changed 4. Encourage the client to remain in the recliner as much as possible