CH 60 EAQ Spinal Cord Problems

A nurse is monitoring a patient with spinal cord injury. The nurse reviews the arterial blood gas (ABG) reports and notifies the health care provider that the patient may need mechanical ventilation. Which blood gas abnormality would have led the nurse to this opinion? Select all that apply. a. pH = 7.27 b. PaO 2 = 80 mm Hg c. PaCO 2= 55 mm Hg d. PaHCO 3 = 26 mm Hg

ANS: A C

What type of blunt trauma can lead to a spinal cord injury? a. Stab wound b. Diving accident c. Gunshot wound d. Torn spinal cord

ANS: B A diving accident is a blunt trauma caused by a physical injury that can lead to spinal cord injury. Stab wound, gunshot wounds, and a torn spinal cord are instances of penetrating traumas that can injure the spinal cord.

A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply. a. Tachycardia b. Bradycardia c. Hypotension d. Hypertension e. Peripheral vasodilation f. Peripheral vasoconstriction

ANS: B C E A spinal cord injury above T-6 leads to dysfunction of the sympathetic nervous system, which may result in neurogenic shock, indicated by peripheral vasodilation, bradycardia, and hypotension. Tachycardia, hypertension, and peripheral vasoconstriction typically only occur if the sympathetic system is intact.

A patient with spinal cord injury is suspected of having deep vein thrombosis. The health care provider advises the nurse to administer low-molecular-weight heparin. What should the nurse assess before initial administration of the drug? Select all that apply. a. Gastroenteritis b. Signs of any infection c. Signs of any internal bleeding d. Any history of recent surgeries e. Signs of any respiratory distress

ANS: C D Low-molecular-weight heparin (e.g., enoxaparin) is used to prevent venous thromboembolism unless contraindicated. Contraindications include internal bleeding and recent surgery. Low-weight heparin can be administered in the presence of any infection, respiratory problems, or gastroenteritis.

Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? a. Urinary catheterization b. Administration of benzodiazepines c. Suctioning of the patient's upper airway d. Placement of the patient in the Trendelenburg position

ANS: A Because the most common cause of autonomic dysreflexia is bladder irritation, immediate catheterization to relieve bladder distention may be necessary. Benzodiazepines are contraindicated and suctioning is likely unnecessary. The patient should be positioned upright.

A patient with a history of prostate cancer is admitted to the hospital with severe back pain interfering with activity. A computerized tomography (CT) scan shows a metastatic tumor in the spine. Intravenous dexamethasone is prescribed. What is the desired effect of the medication? a. Decrease tumor-related edema. b. Lower the systolic blood pressure. c. Control elevated serum glucose levels. d. Improve muscular strength in the lower extremities.

ANS: A Dexamethasone, a potent corticosteroid, is given intravenously to decrease inflammation and edema. The pain in the spine area decreases when compression of the spinal cord and ischemia to the area is improved. The medication will not affect muscle strength. Corticosteroid therapy tends to increase blood pressure because of sodium retention and elevate serum glucose levels caused by altered carbohydrate metabolism.

The nurse is performing a musculoskeletal assessment on the older patient. Which is the most important factor considered by the nurse when performing the musculoskeletal assessment on the older patient? a. Dietary habits b. Exercise practices c. Psychosocial status d. Present medication list

ANS: B To find out the impact of age-related changes, the nurse needs to know what type of exercise, frequency, and warm-up activities the patient does. Even though dietary habits, psychosocial status, and medications are informative, the exercise regimen is the most important factor when performing a musculoskeletal assessment.

The nurse is caring for a patient with a spinal cord injury who demonstrates motor paralysis and a loss of pain and temperature sensation below the level of injury. What may be the causative factor of this condition? a. Damage to the central spinal cord b. Damage to the anterior spinal artery c. Damage to the posterior spinal artery d. Damage to one-half of the spinal cord

ANS: B The causative factor for motor paralysis, loss of pain, and temperature sensation is damage to the anterior spinal artery. A damage to the central spinal cord results in motor weakness and sensory loss in the upper and lower extremities. Loss of pain and temperature sensation below the level of injury is caused when one-half of the spinal cord is damaged. Damage to the posterior spinal artery affects the dorsal column, which results in a loss of proprioception.

What instructions should the nurse give to the patient and caregivers to prevent skin breakdown in the patient with spinal cord injury who can sit in the wheelchair? Select all that apply. a. Use special mattresses to reduce pressure. b. Use wheelchair cushions to reduce pressure. c. Use pillows to protect bony prominences when in bed. d. If in a wheelchair, lift oneself up and shift weight every two to four hours. e. If in bed, change positions using a regular turning schedule of six hours.

ANS: A B C For preventing skin breakdown in the patient with spinal cord injury, the nurse should teach the patient and caregivers to use special mattresses and wheelchair cushions to reduce pressure. Pillows should be used to protect bony prominences when in bed. If in a wheelchair, the patient should be told to lift him- or herself up and shift weight every 15 to 30 minutes to promote circulation. If in bed, position should be changed every two hours.

The nurse is caring for a patient admitted to the hospital after a motor vehicle accident. The patient is unable to breathe independently and has been intubated and placed on a ventilator. On the basis of these data, which injury does the nurse suspect? a. C1-3 b. C4 c. C5 d. C6

ANS: A An injury to C1-3 is often fatal. The patient retains movement in the neck and above but has a loss of innervation to the diaphragm and an absence of independent respiratory function. A patient with a C4 injury retains sensation and movement in the neck and above. The patient may be able to breathe without a ventilator. A patient who experiences a C5 injury retains full neck movement and partial shoulder, back, and bicep movement. The patient has a gross ability to move the elbow but is unable to roll over or use the hands. The patient also often has a decreased respiratory reserve. A patient with a C6 injury can move the shoulders and upper back; is able to perform abduction and rotation at the shoulder; and has full biceps to elbow flexion and wrist extension, a weak thumb grasp, and decreased respiratory reserve.

A nurse is caring for a patient who has sustained a spinal cord injury. To prevent autonomic dysreflexia, what should the nurse instruct the patient to avoid? a. Urine retention b. Emotional stress c. Smoking cigarettes d. People with upper respiratory infections

ANS: A Autonomic dysreflexia is a medical emergency that occurs when sensory stimulation below the spinal injury triggers a reaction in the intact autonomic system, with resulting reflex arteriolar spasms that increase blood pressure to an extremely high level. A distended bladder is a common trigger of this condition. Profuse sweating below the level of injury and bradycardia are also seen. Although emotional stress, cigarette smoking, and exposure to upper respiratory infections should be avoided by the patient with a spinal cord injury, these factors are not triggers of autonomic dysreflexia.

A patient with paraplegia has been hospitalized for a week and is not eating anything. What could be the possible causes of patient's anorexia? Select all that apply. a. Depression b. Abnormal taste sensation c. Difficulty in swallowing food d. Hurried feeding by the nurse e. Boredom due to institutional food f. Continuous bed rest and weakness

ANS: A D E F Some patients experience anorexia, which can be due to depression, boredom with institutional food, discomfort at being fed (often by a hurried nurse), or continuous bed rest and weakness. Some patients have a normally small appetite. A paraplegic patient has a thoracic or lumbar cord injury; therefore, dysphagia is not a common problem affecting eating in such patients. Taste sensations are usually intact in such patients, and may not be the cause of anorexia.

The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. What does the nurse know about this injury? a. Differences in drug metabolism are related to the level and completeness of the injury. b. Methylprednisolone (MP) needs to be given intravenously within the first few hours of injury. c. Low-molecular-weight heparin is not used because of the increased risk of bleeding and hemorrhage. d. Vasopressor agents are contraindicated, because they can reduce the blood flow to vital organs.

ANS: A Drug metabolism and pharmacologic properties are altered in SCI and are based upon the level of injury and how completely the spinal cord was injured. The differences in drug metabolism correlate with the level and completeness of injury. In patients with SCI, MP is no longer approved by the Food and Drug Administration (FDA). Unless contraindicated, low-molecular heparin is given to prevent venous thrombolytic embolism (VTE). Vasopressor agents are prescribed in the acute phase of the injury to keep the mean arterial pressure above 90 mm Hg and to improve perfusion to the spinal cord.

A patient with spinal cord injury has been placed on mechanical ventilation due to failure of the diaphragm. Which possible level of spinal cord injury should the nurse suspect in this case? a. C1-C3 b. C5-T6 c. T1-L2 d. Above T5

ANS: A Injury at the C1-C3 spinal level causes damage to the phrenic nerve origin. Therefore, paralysis of the diaphragm takes place, causing respiratory failure. Injuries below C3 do not cause any damage to the phrenic nerve, and the diaphragm is able to contract well. Injury between C5 and T6 causes decreased respiratory reserve. Injuries between T1 and L2 may cause bladder retention. Injuries above T5 may manifest as paralytic ileus.

The nurse is providing care to a patient who is paralyzed from the waist down. Which spinal vertebra injury would have caused this manifestation? a. Lumbar vertebra 1 b. Cervical vertebra 4 c. Cervical vertebra 6 d. Thoracic vertebra 6

ANS: A Injury to lumbar vertebra 1 results in paralysis below the waist. Injury to cervical vertebra 4 results in complete paralysis below the neck. Injury to cervical vertebra 6 results in partial paralysis of the hands and arms and of the lower body. Injury to thoracic vertebra 6 results in paralysis below the chest.

Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia? a. Headache and rising blood pressure b. Irregular respirations and shortness of breath c. Decreased level of consciousness or hallucinations d. Abdominal distention and absence of bowel sounds

ANS: A Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory manifestations, decreased level of consciousness, and gastrointestinal manifestations are not characteristic manifestations.

Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury? a. Bradycardia b. Hypertension c. Neurogenic spasticity d. Bounding pedal pulses

ANS: A Neurogenic shock is caused by the loss of vasomotor tone caused by injury, and is characterized by bradycardia and hypotension. Loss of sympathetic innervations causes peripheral vasodilation, venous pooling, and a decreased cardiac output. Hypertension, neurogenic spasticity, and bounding pedal pulses are not seen in neurogenic shock.

Which is a priority nonoperative treatment following a spinal cord injury? a. Stabilization b. Spinal fusion c. Cervical traction d. Pain management

ANS: A Stabilization eliminates any damaging motion at the injury site to avoid worsening the patient's condition. Pain management is important, but it is a lower priority than stabilization. Spinal fusion is a surgical procedure. Cervical traction is a closed reduction with skeletal traction and is used for early realignment (reduction) of the injury; the patient should be stabilized before a care plan is implemented.

The nurse is caring for a patient with paraplegia who is at a risk of developing deep vein thrombosis (DVT). What interventions are expected to be done for this patient? Select all that apply. a. Assess thighs and calves for signs of DVT. b. Administer prophylactic low-dose low-molecular-weight heparin. c. Obtain venous Doppler reports before applying compression stockings. d. Perform passive movements with the patient once deep vein thrombosis is established. e. Ensure that the patient wears compression stockings continuously throughout the day.

ANS: A B C Nursing interventions in paraplegics should be aimed at preventing DVT. Assessment of the thighs and calves should be done every shift for signs of DVT. Venous duplex studies may be performed before applying compression devices. Sequential compression devices or compression gradient stockings can be used to prevent thromboemboli and to promote venous return. Remove the stockings every eight hours for skin care. Low-molecular-weight heparin should be administered as a prophylactic measure to prevent thromboembolism. Once deep vein thrombosis is established, it is not advisable to move the limbs, because this may dislodge the thrombus, and pulmonary embolism, which is a life-threatening complication of DVT, may occur.

A patient has been admitted to the hospital with a T3-level complete spinal cord injury. The nurse has to plan the home-based rehabilitation for this patient. When creating the care plan, the nurse considers the activities that the patient is able to do independently. What activities should the nurse consider to make maximum use of patient's abilities? Select all that apply. a. Independent self-care is possible. b. Independent wheelchair mobility is possible. c. Patient may be able to drive with hand controls. d. Patient will be able to climb stairs independently. e. Patient will be able to have effective coughing ability.

ANS: A B C The patient with a T3-level spinal cord injury will have full innervation of the upper extremities, back, essential intrinsic muscles of the hands, full strength and dexterity of grasp, decreased trunk stability, and decreased respiratory reserve. Therefore, the patient may have the following potentials: full independence in self-care and in a wheelchair, ability to drive a car with hand controls, independent standing in a standing frame. Abdominal muscles are affected, so the ability to cough is lost. The patient may also not be able to climb stars due to the injury.

A patient with spinal cord injury has poor nutritional intake. What measures should the nurse take to improve the patient's nutrition? Select all that apply. a. Provide adequate time to eat. b. Encourage intake of dietary fiber. c. Keep a calorie count of the food taken. d. Provide a pleasant eating environment. e. Provide a low-protein and low-calorie diet. f. Feed the patient only hospital-cooked food

ANS: A B C D General measures such as providing a pleasant eating environment, allowing adequate time to eat (including any self-feeding the patient can achieve), encouraging the family to bring in special foods to avoid the patient becoming bored with institutional food, and planning social rewards for eating may be useful to improve nutrition of the patient. Keep a calorie count, and record the patient's daily weight to evaluate progress. If feasible, the patient should participate in recording caloric intake. Dietary supplements may be necessary to meet nutritional needs. Increased dietary fiber should be included to promote bowel function. Because there is severe catabolism taking place, a high-protein, high-calorie diet is necessary for energy and tissue repair.

An older adult person has fallen from a step stool and has a lower sacral fracture. The investigation reports also show that there is injury to the conus medullaris. What are the symptoms that the nurse should expect while assessing the patient? Select all that apply. a. Bowel incontinence b. Urinary incontinence c. Difficulty in breathing d. Hypotonicity of the lower limbs e. Hypotonicity of the upper limbs

ANS: A B D Conus medullaris, or cauda equina syndrome, results from damage to the conus (lowest portion of the spinal cord) and cauda equina (lumbar and sacral nerve roots). It is characterized by flaccid paralysis of the lower limbs and areflexic (flaccid) bladder and bowel. There may be decreased anal tone and consequent fecal incontinence. Upper limbs are not affected by injury to the conus. Breathing is not affected, because the injury is to the conus medullaris, which does not control muscles of breathing.

A patient with a cervical spinal cord injury has just been hospitalized. Which nursing interventions for maintaining nutritional balance, if prescribed, are appropriate for this patient? Select all that apply. a. Insert a nasogastric tube. b. Evaluate swallowing before starting oral feeding. c. Prescribe a low-protein and low-carbohydrate diet. d. If oral feeding is not possible, enteral nutrition must be provided. e. Gradually introduce oral food and fluids, irrespective of bowel sounds.

ANS: A B D During the first 48 to 72 hours after the injury, the gastrointestinal (GI) tract may stop functioning (paralytic ileus), and hence a nasogastric tube must be inserted. In patients with high cervical cord injuries, evaluate swallowing before starting oral feedings. If the patient is unable to resume eating, enteral nutrition may be used to provide nutritional support. Once bowel sounds are present or flatus is passed, gradually introduce oral food and fluids. Because of severe catabolism, a high-protein, high-calorie diet is necessary for energy and tissue repair.

A quadriplegic patient has been hospitalized for one month, and is therefore at a risk of developing pressure sores. What are the steps that the nurse should take to prevent the development of pressure ulcers? Select all that apply. a. Check the nutritional status of the patient. b. Check the patency of the urinary catheter. c. Change the position of the patient every six hours. d. Avoid lifting the patient when changing the position. e. Check bony prominences for signs of pressure sores.

ANS: A B E Prevention of pressure ulcers and other types of injury to insensitive skin is essential for every patient with a spinal cord injury (SCI). Moisture from incontinence or any urine leakage can contribute to pressure ulcer development by macerating the skin and increasing friction injuries. Assess nutritional status regularly. A comprehensive visual and tactile examination of the skin should be done at least once daily, with special attention given to areas over bony prominences. The areas most vulnerable to breakdown include the ischia, trochanters, heels, and sacrum. Both body weight loss and weight gain can contribute to skin breakdown. When a patient is moved, it must be done in a way to prevent friction and shearing, because these forces will cause skin injury as readily as pressure. The patient must be lifted, not dragged, while repositioning, which also means more than one person may be needed to move the patient. Pulling or dragging the patient will cause skin damage due to friction. Careful positioning and repositioning should be done every two hours.

Which interventions should be included in the teaching plan for the patient with paraplegia who is discharged from a rehabilitation facility? Select all that apply. a. Use pressure-relief devices while sitting. b. Change position at least every two hours. c. Apply massage to areas with sustained redness. d. Follow a diet high in vitamins and low in protein. e. Inspect all skin areas on a daily basis using a mirror as necessary.

ANS: A B E Prevention of skin breakdown is the goal for patients with paraplegia (paralysis of the lower extremities). The patient should inspect the skin, especially pressure areas and bony prominences, at least every 24 hours. Minimally, patients need to change position every two hours to prevent pressure sore development. Because patients sit much of the time, pressure relief devices are needed, especially on wheelchairs. Skin that remains reddened after 30 minutes is showing signs of pressure damage. Massaging the areas will add to the injury. A diet with adequate vitamins and adequate protein is needed to maintain skin integrity.

A computed tomography (CT) scan has to be completed for a patient with spinal cord injury. The nurse has to explain the uses of this procedure to the caregivers in order to obtain their consent. What should the nurse tell the caregivers? Select all that apply. a. It helps to find the exact location of injury. b. It helps to diagnose deep vein thrombosis (DVT). c. It helps to assess changes in the neurologic tissue. d. It helps to find the degree of spinal canal compromise. e. It helps to find the presence of any damage to the spinal or vertebral arteries.

ANS: A D For a patient with spinal cord injury, CT scan is the preferred imaging study to diagnose the location and degree of injury and degree of spinal canal compromise. Magnetic resonance imaging is used to assess for soft tissue and neurologic changes and for unexplained neurologic deficits or worsening of neurologic status. Patients with cervical injuries who demonstrate altered mental status may also need a CT angiogram to rule out vertebral artery damage. Duplex Doppler ultrasound, impedance plethysmography, venous occlusion plethysmography, venography, and the clinical examination are recommended for use as diagnostic tests for DVT.

A person who has survived a motor vehicle accident has been diagnosed as having a thoracic level spinal cord injury. A week into hospitalization, the patient is put on mechanical ventilation. The nurse has to explain to the caregivers the reason for mechanical ventilation. What could be the reason for the need for mechanical ventilation in this patient? Select all that apply. a. There is fluid overload in the lungs. b. There is severe constriction of airways. c. The nerve that controls breathing is damaged. d. The muscle responsible for breathing is paralyzed. e. There is accumulation of secretions in the lungs, which has caused collapse of the lungs.

ANS: A D E Cervical and thoracic injuries cause paralysis of abdominal muscles and often the intercostal muscles. Therefore, the patient cannot cough effectively enough to remove secretions, leading to atelectasis and pneumonia. Pulmonary edema may also occur in response to fluid overload. The spinal cord injury is at the thoracic level, so the phrenic nerve and diaphragm are spared. Constriction of larger airways also occurs at a higher spinal cord injury level.

A patient with a T3-level spinal cord injury has been discharged from the hospital with an indwelling catheter for neurogenic bladder. The nurse is teaching the patient regarding the care for indwelling catheters. What instructions should the nurse give regarding home care for indwelling catheters? Select all that apply. a. Cleanse the catheter regularly. b. Always keep the urine bag above the waist. c. Limit water intake to less than a liter a day. d. Check for the presence of any folds or kinks in the catheter tube. e. Check for signs of urinary tract infection (fever, change in odor or color of urine).

ANS: A D E Indwelling catheters should be cleaned regularly, and the method of cleaning should be taught properly by the nurse to the patient to avoid any infections. The patency of the catheter tube should always be checked to prevent any accumulation of urine in the bladder. Long-term use of an indwelling catheter may be associated with urinary tract infection. Signs and symptoms of these conditions should be explained to the patient. The urine bag should always be placed below the level of the bladder to ensure proper drainage. Patients with indwelling catheters need to have an adequate fluid intake (at least 3 to 4 L/day).

A patient with paraplegia has sudden violent movements of the lower limbs. What should the nurse tell the patient and the caregivers about these violent spasms? Select all that apply. a. These spasms can occur as a result of a variety of stimuli. b. This occurs due to hyperexcitability of the upper motor neuron. c. These spasms indicate improvement in the condition of the patient. d. Such reflexes could be positively used for bowel and bladder retraining. e. This occurs due to a break in the link between the upper and lower motor neuron interaction.

ANS: A D E Once the period of spinal shock is resolved, due to lack of control from the higher brain centers, reflexes are often hyperactive and produce exaggerated responses. The upper motor neuron does not have an inhibitory control over the lower motor neuron. Spasms ranging from mild twitches to convulsive movements below the level of injury may also occur. These may occur due to a variety of stimuli. These reflexes are useful in sexual, bowel, and bladder retraining. These spasms do not indicate an improvement in the condition of the patient.

The arterial blood gas (ABG) report of a patient with a spinal cord injury reveals that the patient is in respiratory distress. Which nursing interventions, if prescribed, are appropriate for this patient? Select all that apply. a. Administer oxygen. b. Administer steroids. c. Administer antibiotic drugs. d. Perform tracheal suctioning. e. Use assisted coughing techniques.

ANS: A D E To maintain adequate ventilation, the nurse should administer oxygen until ABGs stabilize. Assisted (augmented) coughing simulates the action of the ineffective abdominal muscles during the expiratory phase of a cough, therefore facilitating the removal of secretions. Tracheal suctioning is performed if crackles or rhonchi are present, as indicated by mucus stuck to the airways. Presence of an infection cannot be revealed by an ABG report; therefore it is not appropriate to administer antibiotics. ABG does not reveal any presence of inflammatory process; therefore it is inappropriate to administer steroids to this patient.

A nurse is planning a bowel program for a patient with a T7 level spinal cord injury. What is the most suitable position for bowel evacuation for this patient? a. Prone position b. Sitting position c. Supine position d. Standing position

ANS: B A patient with T7 level spinal injury will be able to sit; therefore it is best to position the patient upright for proper evacuation, because this position would ensure complete evacuation. The supine position does not facilitate evacuation of the bowels. If the patient is not able to sit upright, it could be done in the side-lying position. The prone position and standing are awkward for bowel evacuation.

While assessing a patient's level of spinal injury, the nurse observes that the patient has sensation and movement in the neck and the region above, and can breathe without a ventilator. What is the potential for rehabilitation that the nurse can expect? a. Ability to feed self with setup b. Ability to drive an electric wheelchair c. Attendant care required for 10 hours in a day d. Independent computer use with adaptive equipment

ANS: B A patient with sensation and movement in the neck and the region above the neck can drive an electric wheelchair by using chin control of a mouth stick. Self-feeding is not possible for the patient because the ability of movement is limited to the neck. The patient requires complete assistance with daily living activities; therefore attendant care is required 24 hours a day. Due to paralysis in the arms and hands, the patient can access the computer only with the help of a mouth stick and head wand. Hence independent use of a computer is not possible.

The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following? a. Central cord syndrome b. Spinal shock syndrome c. Anterior cord syndrome d. Brown-Séquard syndrome

ANS: B About 50 percent of people with acute spinal cord injury experience a temporary loss of reflexes, sensation, and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and sensory loss that is greater in the upper extremities than in the lower extremities. Anterior cord syndrome results in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss of motor function and contralateral loss of sensory function.

A patient with facial paralysis comes to the walk-in clinic and is diagnosed with Bell's palsy. What does the nurse understanding about this disorder? a. Has a poor prognosis b. Can affect any age group c. Can occur on both sides of the face. d. Affects more than 100,000 people every year

ANS: B Bell's palsy is a type of peripheral facial paralysis that can affect any age group, although it commonly is seen in the 20- to 60-year-old range. The cause is not well known; it may be theorized that Bell's palsy can be related to activation of herpes simplex virus (HSV-1). It has a good prognosis. It is characterized by facial-nerve inflammation (CN-VII) on one side of the face, in the absence of any other disease such as stroke. Bell's palsy occurs on only one side of the face and more than 40,000 Americans are afflicted each year.

A patient is admitted to the hospital after sustaining a C7 spinal cord injury. What is the most important nursing intervention during the acute stage of care? a. Monitoring vital signs b. Maintaining a patent airway c. Maintaining proper body alignment d. Turning and repositioning the patient every two hours

ANS: B Initial care for a patient with a C7 spinal cord injury is focused on establishing and maintaining a patent airway and supporting ventilation. Even though the injury is located at C7, spinal edema may extend to the C4 level and cause paralysis of the diaphragm. Therefore the effects and extent of edema are unpredictable, initially necessitating close monitoring of respiratory status. Monitoring the vital signs and maintaining proper body alignment are important nursing interventions but are not as high a priority as maintaining a patent airway. Turning and repositioning the patient every two hours depends on the stability of the spinal cord injury and the status of spinal precautions. A patient with a spinal cord injury may require a specialty bed or device.

The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation? a. Polyneuropathy b. Spinal cord injury c. Spinal cord tumor d. Cranial nerve disorder

ANS: B Poikilothermia is the inability to maintain body temperature. It is one of the manifestations of spinal cord injury. Polyneuropathies may result in weakness of the lower extremities, paresthesia (numbness and tingling), paralysis with muscle incoordination and weakness, stiffness in the jaw and neck, sharp pains in the leg, and ataxia. Spinal cord tumor may result in back pain, coldness, numbness, and tingling in the extremities. Cranial nerve disorders usually result in burning, knifelike, or lightning-like shock in the lips; intense pain, twitching, tinnitus, paralysis of the motor branches of the facial nerve; and drooping of the mouth accompanied by drooling.

A woman has had a T4 level complete spinal cord injury (SCI). She wants to know about the impact of this injury on her sexuality. What information and instructions should the nurse tell her regarding her sexuality? Select all that apply. a. The injury does not cause amenorrhea. b. Precautions for unplanned pregnancy are necessary. c. The patient does have the capacity to become pregnant. d. Erotic and sexual thoughts may not cause vaginal lubrication to take place. e. Fatal complications like autonomic dysreflexia could be associated with pregnancy.

ANS: B C D E The injury does not affect the ability to become pregnant or to deliver normally through the birth canal. If sexual activity is resumed, protection against an unplanned pregnancy is necessary. Women with upper motor neuron injuries may retain the capacity for reflex lubrication, whereas psychogenic lubrication, which is dependent on sexual thought processes, depends on the completeness of injury. A normal pregnancy may be complicated by urinary tract infection (UTI), anemia, and most fatal of all, autonomic dysreflexia. Menses may cease for as long as six months after the spinal cord injury. The woman of childbearing age with an SCI usually remains fertile.

A patient with spinal cord injury is paralyzed below the waist. The patient is completely dependent for all care, is withdrawn, and sleeps excessively. The patient states to the nurse, "I can't believe this is happening to me." Which nursing actions are appropriate for this patient? Select all that apply. a. Show sympathy towards the patient. b. Encourage the patient to set daily goals. c. Encourage the patient to participate in care. d. Explain the injury using written teaching material. e. Teach the patient what to expect during the rehabilitation period.

ANS: B C E Appropriate nursing actions include encouraging the patient to participate in care, allowing the patient to make daily goals, and teaching the patient what to expect during the rehabilitation process. Although the nurse should empathize with the patient, sympathy is not a therapeutic action. The use of written material may not be the best way to teach this patient at this time.

A nurse is preparing a teaching plan for a patient with spinal cord injury. What information about nutritional therapy should the nurse include in the plan for the patient and the caregiver? Select all that apply. a. Include spicy food to improve taste. b. Include two servings from the milk group. c. Eat three well-balanced meals each day. d. Include beans in the diet to increase fiber intake. e. Include two or more servings from the meat group.

ANS: B C E For maintaining adequate nutrition in the patient with spinal cord injury, the nurse should instruct the patient to eat three well-balanced meals per day. Food items should be included from the milk and the meat group to increase protein intake. Beans should be avoided, because they can cause formation of gas. Spicy food should also be avoided, because it can cause gastrointestinal upset.

A patient with spinal cord injury has begun to get stress ulcers. What nursing interventions should be performed for this patient? Select all that apply. a. Withhold antacids. b. Check stools for blood. c. Motivate the patient and provide a stress-free environment. d. Obtain prescriptions for increased dosage of corticosteroids. e. Administer proton pump inhibitors for prophylaxis as prescribed.

ANS: B C E In spinal cord injuries, stress ulcers are an important complication resulting from the physiologic response to severe trauma, the psychologic stress associated with the injury, and treatment with high-dose corticosteroids. The stress ulcers usually appear between 6 to 14 days after injury. Stool and gastric contents should be daily checked for presence of blood. Prophylactic treatment with histamine (H 2)-receptor blockers like ranitidine or proton pump inhibitors like pantoprazole helps in decreasing the secretion of HCl acid and prevents ulcers during the initial phase. Antacids should be given along with corticosteroids to prevent development of stress ulcers.

A patient has a T7-level complete spinal cord injury (SCI). He wishes to discuss the related sexual problems with the nurse. What information and advice regarding sexual dysfunction should the nurse give the patient? Select all that apply. a. Male fertility will not be affected by the injury. b. A reflex erection could be easily elicited in the patient. c. The patient may have erectile dysfunction that can be treated. d. The patient's ability to have psychogenic erections is not affected. e. Vacuum suction devices help in improving blood flow to the penis.

ANS: B C E Men with complete injuries are less likely to experience psychogenic erections. However, most men with SCI are able to have a reflex erection with physical stimulation, regardless of the extent of the injury if the S2-S4 nerve pathways are not damaged. Treatment for erectile dysfunction includes drugs, vacuum devices, and surgical procedures. If sildenafil (Viagra) fails to improve erectile dysfunction, vacuum suction devices use negative pressure to encourage blood flow into the penis. Male fertility is affected by SCI, causing poor sperm quality and ejaculatory dysfunction.

A patient is suspected of having cervical cord injury following a motor vehicle accident. Which nursing interventions are appropriate for this patient to stabilize the cervical spine? Select all that apply. a. Avoid "logrolling" of the patient. b. Ensure that the patient's body is correctly aligned. c. Use a sternal-occipital-mandibular immobilizer brace. d. Use a soft cervical collar to stabilize the cervical spine. e. Use a firm backboard to prevent any spinal movement.

ANS: B C E Proper immobilization of the neck involves the maintenance of a neutral position. This can be obtained by use of a hard cervical collar and a backboard to stabilize the neck to prevent lateral rotation of the cervical spine. The nurse should ensure that the body is always correctly aligned. The patient can also use a sternal-occipital-mandibular immobilizer brace. A soft collar is not sufficient to immobilize the cervical spine. When turning the patient, the patient's body should be moved as a unit (i.e., "logrolling") to prevent movement of the spine.

A patient with spinal cord injury has to be catheterized. Which nursing interventions will help to prevent urinary tract infection (UTI)? Select all that apply. a. Empty the urine bag whenever it is 25 percent filled. b. Ensure regular and complete drainage of the bladder. c. Start intermittent catheterization once the patient is stabilized. d. Maintain the urine drainage bag above the level of the bladder. e. Cleanse the patient's genitalia using antiseptic before placing the catheter.

ANS: B C E UTIs are a common problem in patients with spinal cord injuries. The best method for preventing UTIs is regular and complete bladder drainage. After the patient is stabilized, the best means of managing long-term urinary function should be assessed. Usually the patient is started on an intermittent catheterization program. The other common yet important intervention that a nurse could utilize is to use aseptic methods while inserting the catheter, like cleaning the genitalia using antiseptic. The urine bag should be drained every eight hours or when filled about two thirds. When catheterized for a long period, the urine bag should be kept below the level of the bladder; this will prevent backflow of urine and guard against infections.

A patient with a T1-level spinal cord injury is soon to be discharged from the hospital. The nurse has to plan the home care for neurogenic bowel management. What should the nurse include in the care plan? Select all that apply. a. Teach the Valsalva maneuver. b. Explain the use of stool softeners. c. Advise the patient to eat a high-fiber diet. d. Advise the patient to limit fluids in the diet. e. Teach the patient how to use suppositories for evacuation. f. Teach the patient to perform digital stimulation of the rectum.

ANS: B C E F Careful management of bowel evacuation is necessary in the patient with spinal cord injury (SCI) because voluntary control of this function may be lost. This condition is called neurogenic bowel. A stool softener such as docusate sodium can be used to regulate stool consistency. A digital stimulation (performed 20 to 30 minutes after suppository insertion) by the nurse or patient may be necessary. In addition, suppositories (bisacodyl or glycerin) or small-volume enemas can be used. The usual measures for preventing constipation include a high-fiber diet and adequate fluid intake. However, these measures by themselves may not be adequate to stimulate evacuation. The Valsalva maneuver requires intact abdominal muscles, so it is used in those patients with injuries below T12. A high intake of fluid is advised for easier bowel evacuation.

A nurse is assessing a patient with a T2-level spinal cord injury. The nurse notices that there is a kink in the catheter, the bladder is distended, and the blood pressure is 220/100 mm Hg. What nursing interventions would be appropriate for this patient if the nurse suspects autonomic dysreflexia? Select all that apply. a. Lower the head of the bed. b. Monitor blood pressure regularly. c. Make the patient lie flat on the bed. d. Notify the primary health care provider. e. Check for the presence of bowel impaction. f. Remove the kink in the catheter and drain the bladder.

ANS: B D E F A sudden rise in blood pressure for a spinal cord injury patient above the level of T6 is generally indicative of autonomic dysreflexia. Nursing interventions in a serious emergency like autonomic dysreflexia include notifying the primary health care provider and determining the cause. The blood pressure should be regularly monitored; administration of an alpha-adrenergic blocker or an arteriolar vasodilator is required. Contractions of the rectum are also a cause; therefore, the nurse should check for bowel impaction and treat it accordingly. The most common cause is bladder distension. If a catheter is present, the presence of any kinks or folds should be checked. However, the most important nursing intervention in this case is elevating the head of the bed 45 degrees or higher to make the patient sit upright; this would lower the blood pressure.

A patient has been admitted to the hospital with a spinal cord injury. Following the assessment, the health care provider concludes that the injury is above T12. What signs and symptoms related to the gastrointestinal system would indicate an injury above T12? Select all that apply. a. The patient has an absence of bowel sounds. b. There is excess gastric distention, and the stomach is hard. c. The patient is constipated and is passing hard stools with straining. d. The sensation of a full bowel is perceived by the patient, and fecal incontinence is present. e. The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.

ANS: B E An injury above T12 leads to development of a reflexic bowel, wherein nervous interactions between the colon (large intestine) and the brain are interrupted. As a result, the person may not feel the need to have a bowel movement. However, stool is still building up in the rectum. The build-up triggers a reflex, causing the rectum and colon to react, leading to a bowel movement without warning. When the sensation of a full bowel is perceived by the patient and the patient has fecal incontinence, it is a lower-level spinal cord injury (below T12). In spinal cord injury, it is usually incontinence that occurs. When the injury is above T5, paralytic ileus may be present and bowel sounds may be absent.

A patient has been admitted with T2-level spinal cord injury and has abnormal cardiovascular signs and symptoms. Which drugs should the nurse administer to stabilize the condition of this patient? Select all that apply. a. Digoxin b. Atropine c. Metoclopramide d. Vasodilator drugs e. Vasopressor drugs

ANS: B E Due to the spinal cord injury at the T2 level, the patient may have abnormal cardiac signs and symptoms like bradycardia, peripheral vasodilation, and hypotension. Atropine should be administered to increase the heart rate and prevent hypoxemia. Hypotension should be treated by administering IV fluids or vasopressor drugs. Vasodilators would accentuate the peripheral pooling of blood, thereby worsening the condition. Digoxin is used to treat arrhythmias like ventricular tachycardia, and they act by reducing the heart rate. The patient has bradycardia, so digoxin administration would worsen the condition. Metoclopramide is not given for cardiac condition; it is used to treat delayed gastric emptying.

What health promotion activity will have the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older? a. Hearing testing b. Depression screenings c. Fall prevention strategies d. Monitoring blood pressure

ANS: C Falls are the leading cause of SCI in persons 65 years and older. Teaching patients to avoid climbing and using handrails on stairs are ways to prevent falls and injury. Hearing testing, depression screening, and blood pressure monitoring are all ways to promote the health of persons 65 and older, but do not prevent SCI directly.

A patient with a spinal cord injury has a neurogenic bowel. Beyond the use of bisacodyl suppositories and digital stimulation, which measures should the nurse teach the patient and the caregiver about to assist the patient with bowel evacuation? Select all that apply. a. Drink more milk b. Use oral laxatives every day c. Eat 20 to 30 g of fiber per day d. Drink 1800 to 2800 mL of water or juice e. Establish bowel evacuation time at bedtime

ANS: C D The patient with a spinal cord injury and neurogenic bowel should eat 20 to 30 g of fiber and drink 1800 to 2800 mL of water or juice each day. Milk may cause constipation. Daily oral laxatives may cause diarrhea and are avoided unless necessary. Bowel evacuation time usually is established 30 minutes after the first meal of the day to take advantage of the gastrocolic reflex induced by eating.

A patient with a spinal cord injury (SCI) at the level of the seventh cervical vertebra (C7) has experienced episodes of autonomic dysreflexia. What signs and symptoms occur with this condition? Select all that apply. a. Involuntary stool b. Severe drop in blood pressure c. Sudden onset of severe headache d. Sweating above the level of the SCI e. Flushed face and chest above the level of the SCI

ANS: C D E Autonomic dysreflexia is a condition that can occur in persons with SCI at the level of the sixth thoracic vertebra (T6) or higher. A sensory receptor (as with a distended bladder) is stimulated below the level of injury and the sympathetic nervous system responds with vasoconstriction. This is not mediated by the parasympathetic nervous system, but caused by the SCI. Thus the patient develops severe hypertension, often with bradycardia. The causative factors also include rectal distension or skin stimulation. The causative factor must be alleviated as soon as possible. The sympathetic stimulation causes flushing of the face and sweating above the site of the SCI. The rapid rise in blood pressure gives the patient a severe headache. The patient does not have bowel function, so an involuntary bowel movement will not occur. The condition causes severe hypertension, not hypotension.

A patient has been admitted to the hospital with spinal cord injury at the upper thoracic level. The health care provider informs the caregiver that the patient is in a state of neurogenic shock. How should the nurse explain the term neurogenic shock to the caregivers? Select all that apply. a. Blood pressure and heart rate have increased. b. Blood vessels in the extremities have constricted. c. There is loss of nervous control of the blood vessels. d. The amount of blood pumped out of the heart reduces. e. There is pooling of blood in the veins of the extremities.

ANS: C D E Neurogenic shock is due to the loss of vasomotor tone caused by spinal cord injury. Loss of sympathetic nervous system innervation causes peripheral vasodilation, venous pooling, and decreased cardiac output. It is chiefly characterized by hypotension and bradycardia, not increased blood pressure and heart rate. The blood vessels in the extremities dilate due to neurogenic shock.

A person is injured in a motor vehicle accident and is brought into the emergency department. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred? a. Initiation of intravenous access peripherally. b. Maintenance of an open airway using the head tilt method. c. Determination if the patient is oriented to person, place, and time. d. Applying a rigid cervical collar and using a backboard to transport the patient.

ANS: D Application of a rigid neck collar and use of a backboard will immobilize and stabilize the cervical spine to limit immediate injury to the spinal cord. Initiation of intravenous access is important but is not directly associated with limiting the SCI. Patient orientation will not stabilize a SCI. The airway must be maintained with the jaw thrust technique if SCI is suspected.

The nurse is providing care to a patient with a spinal cord injury as the result of a motor vehicle accident. The nurse notes that the patient feels no pain in the leg on the side opposite the injury. Which spinal cord syndrome does the nurse suspect based on the assessment data? a. Central cord syndrome b. Anterior cord syndrome c. Cauda equina syndrome d. Brown-Séquard syndrome

ANS: D Brown-Séquard syndrome results from damage to one half of the spinal cord. A contralateral (opposite side of the injury) loss of pain and temperature sensation below the level of the injury is a manifestation of the syndrome. Central cord syndrome is caused by damage to the central spinal cord. Motor weakness and sensory loss are the common manifestations of this syndrome. Anterior cord syndrome is caused by damage to the anterior spinal artery and often results in motor paralysis and loss of temperature and pain sensation below the level of the injury. Cauda Equina syndrome results from damage to the lowest portion of the spinal cord. Flaccid paralysis of the lower limbs and areflexic bladder and bowel are the common manifestations.

The nurse is providing care to a patient with a penetrating spinal cord injury. The patient has ipsilateral loss of motor function and position and vibratory sense vasomotor paralysis. Which syndrome does the nurse document in this client? a. Central cord syndrome b. Anterior cord syndrome c. Posterior cord syndrome d. Brown-Séquard syndrome

ANS: D Brown-Séquard syndrome results from damage to one half of the spinal cord. This syndrome is typically caused by a penetrating spinal cord injury and results in a loss of motor function on the same side as the injury. Central cord syndrome is caused by damage to the central spinal cord, resulting in motor weakness and sensory loss in both the upper and lower extremities. Anterior cord syndrome is caused by damage to the anterior spinal artery that results in compromised blood flow to the anterior spinal cord. Motor paralysis and loss of pain and temperature sensation are manifestations. Posterior cord syndrome results from damage or compression to the posterior spinal artery. It is a rare condition that manifests as loss of proprioception.

The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate? a. Central cord syndrome b. Posterior cord syndrome c. Brown-Séquard syndrome d. Conus medullaris syndrome

ANS: D Conus medullaris syndrome results from damage to the conus, the lowest part of the spinal cord; it causes flaccid paralysis of the lower limbs and areflexic bladder and bowels. Central cord syndrome is caused by damage to the central spinal cord; it results in motor weakness and sensory loss in the upper and lower extremities. Posterior cord syndrome results from damage to the posterior spinal artery; it usually results in a loss of proprioception. Brown-Séquard syndrome is caused by damage to one half of the spinal cord; it results in ipsilateral and contralateral paralysis.

Which diagnostic study is used to assess soft tissue injury and neurologic changes? a. Doppler ultrasound b. Cervical radiography c. Computed tomographic (CT) scan d. Magnetic resonance imaging (MRI)

ANS: D MRI is used to assess soft tissue injury and neurologic changes. A cervical radiograph is used when a CT scan is not readily available. Doppler ultrasound is used to diagnose deep vein thrombosis. A CT scan is used to diagnose the location and degree of injury and the degree of spinal canal compromise.

After learning about rehabilitation for a spinal cord tumor, which statement shows that the patient understands what rehabilitation is and can do for him or her? a. "I want to be rehabilitated for my daughter's wedding in two weeks." b. "Rehabilitation will be more work done by me alone to try to get better." c. "I will be able to do all my normal activities after I go through rehabilitation." d. "With rehabilitation, I will be able to function at my highest level of wellness."

ANS: D Rehabilitation is an interdisciplinary endeavor carried out with a team approach to teach and enable the patient to function at the patient's highest level of wellness and adjustment. It will be a lot of work for all involved and takes longer than two weeks. With neurologic dysfunction, the patient will not be able to do all the normal activities in the same way as before the lesion, so this statement should be discussed.

A patient has been admitted with a C5-level spinal cord injury and has marked hypotension. What pharmacologic therapies would the nurse expect to be prescribed for this patient? Select all that apply. a. Nitrates b. Diuretics c. Beta blockers d. Anticoagulants e. Intravenous fluids

ANS: D E The spinal cord injury at the C5 level causes loss of sympathetic nervous system tone in peripheral vessels. This results in chronic low blood pressure with potential postural hypotension. Lack of muscle tone to aid venous return can result in sluggish blood flow, thus predisposing the patient to deep vein thrombosis. To treat hypotension, a vasopressor agent such as dopamine or norepinephrine should be administered. Fluid replacement also helps in maintaining optimal blood pressure. Nitrates are potent vasodilators and would worsen the hypotension if administered. Diuretics increase fluid loss from the body and may worsen hypotension. Beta blockers decrease the heart rate and cardiac output, which lower blood pressure and make the heart beat more slowly and with less force; this is inappropriate to treat hypotension.

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

ANS:: D Maintaining a patent airway is the most important goal for a patient with a high cervical fracture. Although the risk for impairment of tissue integrity, altered patterns of urinary elimination, and altered family and individual coping are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory needs are always the highest priority. Remember airway, breathing, and circulation (ABCs).