CH 60 EAQs Spinal Cord
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.
-Administer oxygen -Perform tracheal suctioning -Use assisted coughing techniques
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 fir this patient? Select all that apply.
-Assess thighs and calves for signs of DVT -Administer prophylactic low-dose low-molecular-weight heparin -Obtain venous Doppler reports before applying compression stockings
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.
-Bowel incontinence -Urinary incontinence -Hypotonicity of the lower limbs
A patient with a T-4 injury develops signs of neurogenic shock. Which assessment findings are expected with this complication? Select all that apply.
-Bradycardia -Hypotension -Peripheral vasodilation
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.
-Check stools for blood -Motivate the patient and provide a stress-free environment -Administer proton pump inhibitors for prophylaxis as prescribed
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.
-Cleanse the catheter regularly -Check for the presence of any folds or kinks in the catheter tube -Check for signs of urinary tract infection (fever, change in order or color of urine)
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.
-Eat 20 to 30 g of giber per day -Drink 1800 to 2800 mL of water or juice
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.
-Encourage the patient to set daily goals -Encourage the patient to participate in care -Teach the patient what to expect during the rehabilitation period
A patient with spinal cord injury has to be catheterized. Which nursing intervention will help to prevent urinary tract infection (UTI)? Select all that apply.
-Ensure regular and complete drainage of the bladder -Start intermittent catheterization once the patient is stabilized -Cleanse the patient's genitalia using aseptic before placing the catheter
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.
-Ensure that the patient's body is correctly aligned -Use a soft cervical collar to stabilize the cervical spine -Use a firm backboard to prevent any spinal movement
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.
-Explain the use of stool softeners -Advise the patient to eat a high-fiber diet -Teach the patient how to use suppositories for evacuation -Teach the patient to perform digital stimulation of the rectum
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.
-Include two servings from the milk group -Eat three well-balanced meals each day -Include two or more servings from the meal group
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.
-Insert a nasogastric tube -Evaluate swallowing before starting oral feeding -If oral feeding is not possible, enteral nutrition must be provided
A women 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.
-Precautions for unplanned pregnancy are necessary -The patient does have the capacity to become pregnant -Erotic and sexual thoughts may not cause vaginal lubrication to take place -Fatal complications like autonomic dysreflexia could be associated with pregnancy
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.
-Provide adequate time to eat -Encourage intake of dietary fiber -Keep a calorie count of the food taken -Provide a pleasant eating environment
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.
-Signs of any internal bleeding -Any history of recent surgeries
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.
-Sudden onset of severe headache -Sweating above the level of the SCI -Flushed face and chest above the level of the SCI
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 the patient? Select all that apply.
-There is fluid overload in the lungs -The muscle responsible for breathing is paralyzed -There is accumulation of secretions in the lungs, which has caused collapse of the lungs
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.
-There is loss of nervous control of the blood vessels -The amount of blood pumped out of the heart reduces -There is pooling of blood in the veins of the extremities
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.
-Use pressure-relief devices while sitting -Change position at least every two hours -Inspect all skin areas on a daily basis using a mirror as necessary
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.
-Use special mattresses to reduce pressure -Use wheelchair cushions to reduce pressure -Use pillows to protect bony prominences when in bed
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?
Ability to drive an electric wheelchair
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?
Applying a rigid cervical collar and using a backboard to transport the patient
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?
Bradycardia
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?
Brown-Sequard syndrome
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 base on the assessment data?
Brown-Sequard syndrome
The nurse is caring for a patient admitted to the hospital after a motor vehicle accident. The patient is unable to breathe independently and had been intubated and placed on a ventilator. On the basis of these data, which injury does the nurse suspect?
C1-3
A patient with spinal cord injury has been placed on a mechanical ventilator due to failure of the diaphragm. Which possible level of spinal cord injury should the nurse suspect in this case?
C1-C3
A patient with facial paralysis comes to the walk-in clinic and is diagnosed with Bell's palsy. What does the nurse understand about this disorder?
Can affect any age group
The nurse is providing care to a patient with a spinal cord injury who has areflexic bladder. Which syndrome does the nurse anticipate?
Conus medullaris syndrome
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?
Damage to the anterior spinal artery
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?
Decrease tumor-related edema
The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. What does the nurse know about this injury?
Differences in drug metabolism are related to the level and completeness of the injury
What type of blunt trauma can lead to a spinal cord injury?
Diving accident
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?
Exercise practices
What health promotion activity will have the greatest impact in the prevention of spinal cord injury (SCI) in adults 65 years and older?
Fall prevention strategies
Which manifestations in a patient with a T4 spinal cord injury should alert the nurse to the possibility of autonomic dysreflexia?
Headache and rising blood pressure
When planning care for a patient with a C5 spinal cord injury, which diagnosis has the highest priority?
Ineffective airway clearance caused by high cervical spinal cord injury
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority?
Ineffective airway clearance caused by high cervical spinal cord injury
The nurse is providing care to a patient who is paralyzed from the waist down. Which spinal vertebra injury would have caused this manifestation?
Lumbar vertebra 1
Which diagnostic study is used to assess soft tissue injury and neurologic changes?
Magnetic resonance imaging (MRI)
A patient is admitted to the hospital after sustaining a C& spinal cord injury. What is the most important intervention during the acute stage of care?
Maintaining a patent airway
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?
Maintaining a patent airway
Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia?
Urinary catheterization
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?
Urine retention
A nurse is planning bowel program for a patient with a T7 level spinal cord injury. What is the most suitable position for bowel evacuation for this patient?
Sitting position
The nurse is caring for a patient with poikilothermia. What condition in the patient's medical record likely caused this clinical manifestation?
Spinal cord injury
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?
Spinal shock syndrome
What is a priority nonoperative treatment following a spinal cord injury?
Stabilization
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?
With rehabilitation, i will be able to function at my highest level of wellness
