Spinal Cord Injury/Autonomic Dysreflexia

The nurse is providing instructions to a client with a spinal cord injury about caring for the halo device. The nurse plans to include which instructions? A. "Begin driving 1 week after discharge." B. "Avoid using a pillow under the head while sleeping." C. "Swimming is recommended to keep active." D. "Keep straws available for drinking fluids."

D. "Keep straws available for drinking fluids

In addition to frequent re-positioning, the nurse anticipates a consultation request for which special pressure relief device to help prevent pressure ulcers in the client with a spinal cord injury? A. Chair pad B. Thromboembolism-deterrent (TED) hose C. Trapeze D. Water bottle

a

in the ED which is the nursing priority in assessing the client with a SCI? a. patent airway b. indication of allergies c. level of consciousness d. loss of sensation

a

Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion

3 ineffective airway clearance is they priority. The nurse utilizes the ABCs (airway, breathing, circulation) to determine priority. With Ineffective Airway Clearance, the patient is at risk for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is the nurse's next priority (circulation), and then Altered Tissue Perfusion. If the patient does not have enough volume to circulate, then tissue perfusion cannot be adequately addressed. The last priority for this patient is Impaired Physical Mobility.

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and complete paralysis of the lower part of the body. The nurse should use which medical term to adequately describe this in documentation?1. hemiplegia2. paresthesia3. paraplegia4. quadriplegia

4 quadriplegia describes complete paralysis of the upper extremeties and complete paralysis of the lower part of the body. hemiplegia describes paralysis on one side of the body. paresthesia does not indicate paralysis. paraplegia is paralysis of the lower body

A hospitalized patient with a C7 cord injury begins to yell "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.

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 symptomology: flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the injury level

the student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates the need for further instruction regarding care of the patient with a spinal cord injury? a. keep the halo jacket fastened unless the pt is in a supine position b. monitor the bladder every 4 hours for signs of bladder distention c. instruct unlicensed assistive personnel to turn and reposition the pt every 2 hours d. assess compression stockings for proper fit

c Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine position in order to prevent sudden head movement. Bladder distention should be avoided to prevent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis.

A client with a T6 spinal cord injury who is on the rehabilitation unit suddenly develops facial flushing and reports a severe headache. Blood pressure is elevated, and the heart rate is slow. Which action does the nurse take first? A. Check for fecal impaction. B. Insert a straight catheter .C. Help the client sit up. D. Loosen the client's clothing.

c - help the client sit up

A client is admitted with a spinal cord injury at the seventh cervical vertebra secondary to a gunshot wound. Which nursing intervention is the priority for this client's care? A. Auscultating bowel sounds every 2 hours B. Beginning a bladder retraining program C. Monitoring nutritional status D. Positioning the client to maximize ventilation potential

d

A client is being discharged with paraplegia secondary to a motor vehicle crash and expresses concern over the ability to cope in the home setting after the injury. Which is the best resource for the nurse to provide for the client? A. Hospital library B. Internet C. Provider's office D. National Spinal Cord Injury Association

d

Which patient is at highest risk for a spinal cord injury?1. 18-year-old male with a prior arrest for driving while intoxicated (DWI) 2. 20-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

1 the three major risk factors for SCI are age (young adults), gender- male, and alcohol or drug abuse. females tend to engage in less risk taking behavior than young men

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

1 2 5 in the emergency setting all pt who have trauma to the head or spine or are unconscious should be tx as though they have a spinal cord injury. immobilizing the neck, maintaining a supine position and securing the pt head to prevent movement are all basic guidelines of emergency care. placement on the ventilator and raiding the HOB will be considered after admittance to the hospital

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which of the following? 1. increased episodes of hypoglycemia 2. possible episodes of hyperglycemia 3. no change in the patient's glycemic parameters 4. both hyper- and hypoglycemic episodes

2 a common side effect of corticosteroids is hyperglycemia. stress as well as the medication could cause this person to have periods of elevated blood sugars

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. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the healthcare provider. 4. Prepare the patient for diagnostic radiography.

2 autonomic dysreflexia occurs in pt with injury at level t6 or higher and is life threatening situation that will require immediate intervention or the pt will die. the most common cause is an overextended bladder or bowel. symptoms include HTN, headache, diaphoresis, bradycardia, visual changes, anxiety and nausea. a calm soothing evironment is fine, though not what the patient needs,

The nurse understands that when the spinal cord is injured, ischemia results and edema occurs. 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 for two cord segments above and below the affected level." 3. "Neurons need time to regenerate so stating the 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." 4. necrosis of gray and white matter does not occur until days after the injury

2 within 24 hrs 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 extend of injury cannot be determined until after the edema is controlled. neurons do not regenerate, and the edema is the factor that limits the ability to predict extent of injury

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient 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."

2 a halo device will allow the patient to be mobile since it does not require weights like the Gardner- wells tongs. the patients pain level is not dependant on the type of stabilization device used. the pt does not have a increase r/o infection with the Gardner Wells tongs; both devices require pins to be inserted into the skull. the time required for stabilization is not dependant on the type

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the following actions is the nurse responsible for when caring for this patient?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

2 4 5 The healthcare provider is responsible for initial applying of the traction device. The weights on the traction device must not be changed without the order of a healthcare provider. 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 and the nurse is responsible for assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is often performed by a physical therapist or a nurse.

While caring for the patient with spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings, and continues to assess vital signs every two to three 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 which of the following? 1. hypoxia 2. bradycardia 3. elevated blood pressure 4. tachycardia

3 autonomic dysreflexia is an emergency that requires immediate assessment and intervention to prevent complications of extremely high blood pressure. additional nursing assistance will be needed and a colleague needs to reach the physician stat

the nurse notes crusting of secretions around the pins of a patient with a halo device. what action should be taken at this time. a. wrap the pins with gauze soaked in NS b. gently pick the crusting off the pins with a dry gauze pad c. apply gauze soaked with hydrogen peroxide around the pins d. syringe 1/2 strength hydrogen peroxide and sterile water to the crusted areas

a if crusting is noted, wrap gauze soaked with NS around the pin site for 15 minutes. after removing the gauze, use a clean cotton tipped applcator to gently remove the crust from the pin site.

The anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent. Which response by the nurse is most helpful? a. motor function sometimes returns after the edema of the spinal cord has subsided b. motor function may improve, but there will always be a deficit c. in all likelihood the paralysis will be permanent d. the physician is the best recourse for information

a until spinal cord edema has subsided, the extent or the permeancy of the paralysis cannot be evaluated. it would be incorrect to indicate that there will definitely be a deficit or paralysis. not adressing the question and suggesting only to talk to the physician may frighten the parent

In the event of autonomic dysreflexia (AD) in the patient with a spinal cord injury, the initial intervention should be to: a.elevate the head of the bed to lower BP b. notify the charge nurse to get assistance c. increase IV fluid rate to ensure adequate circulating volume d. administer anti hypertensive medication

a Autonomic dysreflexia (hyperreflexia) response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of bed is the initial intervention to decrease the rising blood pressure. Notifying the charge nurse can be done after initial interventions. Increasing the IV fluid rate may further increase the blood pressure. The cause of AD should be addressed before administering any hypertensive medication.

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

a Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe common complications of spinal injury associated with bladder distension.

The nurse is caring for a patient who has a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.) a. transferring himself b. dressing himself c. using a cheelchair with standard hand rims d. feeding himself e. effectively typing using all digits

a b c d The patient with an injury at C7 does not have full control of all digits. The third finger is the most functional. With physical and occupational therapy, the patient may be able to perform all other functions listed.

the nurse caring for a patient with autonomic dysreflexia assesses the pt for which conditions or situations a. distended bladder b. constipation c. increased fluid intake d. wrinkles in bed lines e. abrupt environmental temperature changes

abde Bladder distention, constipation, wrinkled bed linens, and temperature changes are potential triggers for autonomic dysreflexia (AD) that the nurse should assess for. This condition causes a rapid increase in blood pressure.

The nurse is caring for a client with a spinal cord injury resulting from a diving accident, who has a halo fixator and an indwelling urinary catheter in place. The nurse notes that the blood pressure is elevated and that the client is reporting a severe headache. The nurse anticipates that the health care provider will prescribe which medication? A. Dopamine hydrochloride (Inotropin) B. Nifedipine (Procardia) C. Methylprednisolone (Solu-Medrol) D. Ziconotide (Prialt)

b

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain by: (Select all that apply.) a.allowing the brain to twist on the brainstem. b.moving forward to strike the anterior interior skull. c.allowing the brain to compress on itself. d.striking the bony area opposite the site of impact. e.losing small amounts of cerebrospinal fluid.

b d In a coup-contrecoup injury, the brain moves forward, striking the anterior interior wall of the cranium, and moves back, striking the bony area opposite the site of the impact, causing two areas of injury.

The nurse is caring for a client in the emergency department whose spinal cord was injured at the level of C7 1 hour ago. Which assessment finding requires the most rapid action? A. Electrocardiographic monitoring shows a sinus bradycardia at a rate of 50 beats/min. B. The client demonstrates flaccid paralysis below the level of injury. C. The client's chest moves very little with each respiration. D. After two fluid boluses, the client's systolic blood pressure remains 80 mm Hg

c

The nurse is teaching a client and her husband about sexuality issues after a spinal cord injury. Which comment by the client indicates a correct understanding of the nurse's instruction? A. "I can no longer become pregnant." B. "If I become pregnant, I cannot give birth." C. "I may still be able to get pregnant." D. "My children will be paralyzed."

c

A family member of a client with a recent spinal cord injury asks the nurse, "Can you please tell me what the real prognosis for recovery is? I don't feel like I'm getting a straight answer." What is the nurse's best response? A. "Every injury is different, and it is too soon to have any real answers right now." B. "Only time will tell." C. "The Health Insurance Portability and Accountability Act requires that I obtain the client's permission first." D. "Please request a meeting with the health care provider."

d

to prevent the leading cause of death for clients with SCI, collaboration with which componet of the heath team is a nursing priority a. nutritional therapy b. occupational therapy c. physical therapy d. respiratory therapy

d A client with a cervical spinal cord injury is at risk for breathing problems resulting from an interruption of spinal innervation to the respiratory muscles. In collaboration with the respiratory therapist, the nurse should perform a complete respiratory assessment, including pulse oximetry for arterial oxygen saturation every 8 to 12 hours to prevent respiratory complications such as pneumonia, pulmonary emboli, and atelectasis. Collaboration with nutritional therapy, occupational therapy, and physical therapy does not help prevent the leading cause of death in clients with spinal cord injury.

The patient who suffered a spinal cord injury (SCI) 3 days ago resulting in flaccid paralysis begins to flex his arm. The concerned family is instructed that this muscle activity may be related to: a. increased intracranial pressure b. increased edema of the cord c. return of voluntary motor activity d. muscle spasms

d Muscle spasms occur several days after the spinal cord injury and are spinal recovery indicators. Concerned family should be reminded that spasms are not necessarily an indication of the return of motor function.

the nurse is reviewing orders written for a pt with a new SCI. which order should the nurse question before completing? a. place on air matress b. insert a ng tube to low suction c. insert indwelling urinary catheter, strict I&Os d. dexamethasone 10 mh IVP now and repeat in 4 hours

d a pt with a SCI is at risk for skin breakdown/ulcers and an air matress is appropriate. a patient with a SCI is at risk for paralytic ileus, septic, or necrotic bowel and a GI bleed. a NG tube to suction is appropriate. an indwelling catheter is appropriate to prevent incontinence, UTIs and kidney disease. current guidelines for the management of acute SCIs no longer recommend the use of corticosteroids for acute SCI.

the latest bp reading for a pt with a SCI is 210/140. what action should the nurse take first a. palpate the bladder for distention b. assess for a bowel impaction c. re-measure the blood pressure d. raise the HOB to 45 degrees

d the HOB should be elevated first so that blood can pool in the lower extremities and help reduce the blood pressure