Spinal Cord Injury Study Questions

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 and repositioning every 2 hours. B. Maintaining proper alignment. C. Maintaining a patent airway. D. Monitoring vital signs.

C. Maintaining a patent airway RATIONALE: ABC's - ensuring the patients airway is the priority

During assessment of a patient with a spinal cord injury at the level of T2 at the rehabilitation center, which of the following findings would concern the nurse the most? A. A heart rate 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 RATIONALE: Most concern is the marked perspiration as that could be a sign of autonomic dysreflexia, which requires immediate intervention by the nurse. This is a high priority than the reddened area; HR is normal; light wheeze may be expected.

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 RATIONALE: Spinal shock causes an absence of reflexes and flaccid extremities

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 RATIONALE: Bradycardia is the only manifestation here of neurogenic shock. Patient would be hypotensive with weak pulses.

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 or muscle tone from below the area of injury. The nurse understands that the client: A. has suffered a complete spinal cord injury (SCI) B. is experiencing spinal shock C. has sustained an upper motor neuron injury D. will be a quadriplegic

B. is experiencing spinal shock RATIONALE: No movement or muscle tone 2 hours after injury is due to spinal shock. Will not know if this is a complete injury, or if patient will be quadriplegic. Breathing is normal indicating likely not upper motor neuron injury.

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 RATIONALE: Highest priority is airway clearance; at C5 the patient has a weak cough

A nurse is caring for a client with a complete T5 spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and a blood pressure of 162/96 mm Hg. The client reports a severe, pounding headache. Which nursing interventions are appropriate for this client? Select all that apply. A. Elevating the head of the bed 90 degrees B. Loosening constrictive clothing C. Using a fan to reduce diaphoresis D. Assessing for bladder distention and bowel impaction E. Administering antihypertensive medication F. Placing the client in a supine position with legs elevated

A. Elevating the head of the bed 90 degrees B. Loosening constrictive clothing D. Assessing for bladder distention and bowel impaction E. Administering antihypertensive medication RATIONALE: Patient is displaying signs of autonomic dysreflexia A- True, sit the patient all the way up to help induce hypotension B - True, constrictive clothing can trigger autonomic dysreflexia C - False. Reduce diaphoresis by fixing the problem! D - True. Most commonly caused by bowel/bladder distension E - True. May be needed to reduce severe BP F - False. Patient should be sat up. Could worsen severe BP.