Chapter 24: Caring for the Patient with Spinal Cord Injuries Kathleen

21. The nurse is caring for a patient who has been diagnosed with an incomplete spinal cord injury (SCI) that has resulted in central cord syndrome. The nurse expects which findings related to this injury? . " Incomplete spinal cord injury" = HD= hypextionsion and Degenerative bone changes. 1. It is likely a result of a hyperextension injury to the cervical spine. 2. Function, if restored, will occur first in the hands. 3. Loss of function will be greatest in the lower extremities. 4. Prognosis for recovery is poor. 5. The patient may have preexisting degenerative bone changes.

1. It is likely a result of a hyperextension injury to the cervical spine. 5. The patient may have preexisting degenerative bone changes.

18. The nurse is providing community education regarding spinal cord injuries to a group of young adults. Which information should the nurse include? Young adults are most likely to suffer a SCI from trauma such as MVAs or sports-related accidents. 1. "The most common cause of spinal cord injury in your age group is trauma from motor vehicle accidents or sports-related accidents." 2. "Spinal tumors are the most common cause of all injuries to the spinal cord and are not dependent on age." 3. "Young people have a poorer survival rate than do older people." 4. "Nontraumatic causes of spinal cord injury such as infection or inflammation are more common in younger people."

1. "The most common cause of spinal cord injury in your age group is trauma from motor vehicle accidents or sports-related accidents."

4. The health care provider orders 2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured intervertebral disc. The nurse has a 1 milliliter (mL) vial containing 10 mg of morphine sulfate. The nurse needs to withdraw ______ mL of morphine sulfate from the vial. 1. 0.25 2. 0.26 3. 0.27 4. 0.28

1. 0.25

5. The health care provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. The nurse withdraws ______ mL of ketorolac from the ampule. 1. 1.25 2. 1.26 3. 1. 27 4. 1.28

1. 1.25

11. Which patient is at highest risk for a spinal cord injury? The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (higher incidence in males), and alcohol or drug abuse.) 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. 18-year-old male with a prior arrest for driving while intoxicated (DWI)

***29. The nurse recognizes that the rehabilitation goal for a patient who has experienced a spinal cord injury (SCI) is to assist the patient in which activities? Select all that apply. Rehabilitation for patients with SCI consists of a comprehensive program designed to help them adapt to the "limitations" imposed by their injury.Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reach the highest level of "independence" possible.Rehabilitation for patients with SCI consists of a comprehensive program designed to help them reintegrate into the "home environment" and community. 1. Adapting to the realization of the patient's limitations 2. Providing the emotional support required for this adjustment 3. Reaching the patient's highest potential for independence 4. Managing the physical pain such injuries cause 5. Assimilating back into the patient's home environment

1. Adapting to the realization of the patient's limitations 3. Reaching the patient's highest potential for independence 5. Assimilating back into the patient's home environment

13. 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? The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a distended bladder to prevent the chain of events that leads to autonomic dysreflexia. (Autonomic dysreflexia (AD) is a potentially life-threatening syndrome involving an abnormal, overreaction of your autonomic nervous system to painful sensory input. It most often happens after a spinal cord injury at or above the sixth thoracic vertebrae) 1. Autonomic dysreflexia 2. Autonomic crisis 3. Autonomic shutdown 4. Autonomic failure

1. Autonomic dysreflexia

31. A patient with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which intervention in the patient's plan of care? Select all that apply. Use of an "abdominal binder" and thigh-high compression stockings will help venous blood return and minimize blood pooling in the abdomen and lower extremities."Vasoactive agents" like "atropine" will support blood pressure and heart rate, thereby having a positive effect on cardiac output.Measuring and recording intake and output will help assess fluid volume status. Dehydration reduces tissue perfusion. SCI AAR. abdominal blinder, atropine , and I & O 1. Fit the patient for an abdominal binder and thigh-length compression stockings. 2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol. 5. Measure and record intake and output.

1. Fit the patient for an abdominal binder and thigh-length compression stockings. 2. Monitor administration of atropine and other vasoactive agents as ordered or by protocol. 5. Measure and record intake and output.

25. A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk? The gastrointestinal effects of spinal shock include gastroparesis, loss of intestinal peristalsis, and ileus. Placement of a nasogastric or oral gastric tube will be necessary in the acute phase of SCI for decompression of the stomach. 1. Insertion of a nasogastric tube 2. Regular assessment of the patient's bowel sounds 3. Administration of a lansoprazole (Prevacid) 4. Elevating the end of the bed to 35 degrees

1. Insertion of a nasogastric tube

17. A patient with a T5 spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition? Select all that apply. The presence of noxious stimuli below the level of the SCI may result in autonomic dysreflexia. A pressure ulcer may cause this complication. Autonomic dysreflexia can be caused by kinked catheter tubing, which allows the bladder to become full and triggers massive vasoconstriction below the injury site, producing the manifestations of this process.Fecal impaction may provide the noxious stimulus that triggers autonomic dysreflexia. T5 = PKF = presense of a pressure ulcer, kink, and fecal impaction 1. Presence of a pressure ulcer 2. Kinked urinary catheter tubing 3. Respiratory congestion 4. Diarrhea 5. Fecal impaction

1. Presence of a pressure ulcer 2. Kinked urinary catheter tubing 5. Fecal impaction

***26. The nurse has assessed a patient who was admitted for rehabilitation after a fall that resulted in hemiplegia. The patient's care plan may require nursing diagnoses related to which concerns? Hemiplegia = SBRI = sensory perception , body image, role performance, and independence. ."Hemiplegia is the Muscle weakness or partial paralysis on one side of the body that can "affect the arms, legs, and facial muscles." 1. Sensory perception 2. Body image 4. Role performance 5. Independence

1. Sensory perception 2. Body image 4. Role performance 5. Independence

30. The nurse is assessing the psychosocial status of a patient who experienced a spinal cord injury. What would provide the best subjective evidence of the patient's state of mind? Assessment of a patient's psychosocial state is best achieved by assessing the patient's own perception of the presence of a support system. 1. The nurse asks the patient to identify members of his support system. 2. The patient says, "I would enjoy some fast food for lunch." 3. The nurse enters the room and finds the patient crying. 4. The patient tells the nurse he was once treated for depression.

1. The nurse asks the patient to identify members of his support system.

19. The school nurse is teaching a session on ways to prevent spinal cord injuries to a group of middle-school students. Which health promotion information should the nurse include? A key to reducing injuries is to protect the head and neck. Wearing a helmet for these activities helps provide that protection. Diving into unfamiliar water or into familiar water that is at an unfamiliar level may result icervical spine injury. The combination of friends and alcohol can reduce the driver's judgment, causing a motor vehicle accident, which is a major cause of SCI. 1. Wear a helmet while riding a bicycle or motorcycle. 2. Eat a well-balanced diet with sufficient calcium. 3. Wear sunglasses. 4. Do not dive into unfamiliar water. 5. Do not ride in a car with someone who has been drinking.

1. Wear a helmet while riding a bicycle or motorcycle. 4. Do not dive into unfamiliar water. 5. Do not ride in a car with someone who has been drinking.

8. 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? A halo device does not require weights as the tongs do, thereby allowing the patient to be mobile. 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. "The halo device will allow me to get out of bed."

12. How should the nurse explain to a patient with a spinal cord injury why the extent of injury cannot be determined for several days to a week? Spinal shock is a state of areflexia that occurs as a result of primary injury. It is not possible to determine the extent of injury until this condition abates. (Areflexia means the absence of deep tendon reflexes. Tendons are the tight cords of tissue that connect muscles to bones. Typically, when you tap on a tendon, it causes the muscle to contract and move involuntarily.) abate =become less intense 1. "Tissue repair does not begin for 72 hours." 2. "We have to wait until spinal shock resolves." 3. "Neurons need time to regenerate, so it is hard to predict how you will progress." 4. "The most serious changes after an injury take days to develop."

2. "We have to wait until spinal shock resolves."

***32. Risk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury (SCI). The nurse would .... SATA To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of stool softener to help establish a regular bowel elimination pattern.To minimize the risk of constipation in a patient with SCI, the nurse should institute a bowel regimen of chemical stimulation such as a suppository to establish a regular bowel elimination pattern. The patient's bowel elimination pattern should be monitored closely to ensure adequate bowel evacuation.Early nutritional support is often achieved through parenteral feedings until enteral feedings are introduced and tolerated. 2. Administer stool softener as prescribed. 3. Institute chemical stimulation to initiate bowel evacuation. 5. Manage parenteral feedings as ordered.

2. Administer stool softener as prescribed. 3. Institute chemical stimulation to initiate bowel evacuation. 5. Manage parenteral feedings as ordered.

*****2. 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? Autonomic dysreflexia occurs in patients with injury at level T6 or higher. It is a life-threatening condition that requires immediate intervention. The most common cause is an overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. 1. Try to calm the patient and make the environment soothing. 2. Assess for a full bladder. 3. Notify the health care provider. 4. Prepare the patient for diagnostic radiography.

2. Assess for a full bladder.

****23. A patient with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit. The nurse realizes that in order to minimize the patient's risk of developing autonomic hyperreflexia, which interventions should be included in the patient's care plan? Autonomic Dysreflexia (AD), sometimes referred to as Autonomic Hyperreflexia, is a potentially life-threatening medical condition that many people with spinal cord injury (SCI) experience when there is a pain or discomfort below their level of injury, even if the pain or discomfort cannot be felt. ABS = "A"bdominal distention, bladder scan, strict output monitoring. (Monitoring lower libs temp is for DVT) 2. Assessing for abdominal distention 3. Bladder scan postvoiding 4. Assessing pulse oximetry levels with vital signs 5. Strict output monitoring

2. Assessing for abdominal distention 3. Bladder scan postvoiding 5. Strict output monitoring

16. The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition? Findings associated with neurogenic shock include hypotension, bradycardia, peripheral vasodilation, and decreased cardiac output. 1. Paraplegia 2. Neurogenic shock 3. High cervical injury 4. Temporary hypovolemia

2. Neurogenic shock

9. 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 response to this medication? A common side effect of corticosteroids is hyperglycemia. Stress as well as the medication could cause periods of elevated blood sugars. 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. Possible episodes of hyperglycemia

34. A patient sustained a C4 fracture in a diving accident. The patient's wife says, "I'll be so glad when he gets off the ventilator so that he can communicate with me." How should the nurse respond to this statement? The patient will likely be on the ventilator for the rest of his life. There are communication methods that can be used while the patient is still on the ventilator. 1. "It may be a few weeks before he is strong enough to breathe on his own." 2. "We don't know if he will be able to talk when we get him off the ventilator." 3. "There are ways we can teach both of you to communicate that will not require his being off the ventilator." 4. "We need to focus on his getting better, not on how he will communicate.

3. "There are ways we can teach both of you to communicate that will not require his being off the ventilator."

20. The nursing assessment confirms that the patient has experienced loss of voluntary motor and sensory function of both upper and lower extremities, as well as bowel and bladder control, due to a spinal cord injury (SCI). The nurse recognizes that which is true regarding this patient?Sata The patient's injuries would result in deep tendon reflex involvement.The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. An injury at this level exhibits all the identified symptoms.Injuries involving the cervical spinal cord result in tetraplegia, or loss of motor and sensory function involving both upper extremities, both lower extremities, bowel, and bladder. ATT "A"ll , "T"he injury, "T"etraplegia 3. All deep tendon reflexes are affected. 4. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. 5. Tetraplegia is the term for the patient's neurological deficiencie

3. All deep tendon reflexes are affected. 4. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. 5. Tetraplegia is the term for the patient's neurological deficiencies.

14. The nurse suspects that a patient with spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse elevates the head of the bed and removes the patient's compression stockings while searching for the cause of this response. Performing these interventions helps to avoid which very dangerous complication of autonomic dysreflexia? 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. 1. Hypoxia 2. Bradycardia 3. Elevated blood pressure 4. Tachycardia

3. Elevated blood pressure

***3. The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse? Guidelines for emergency care are avoiding flexing, extending, or rotating the neck; immobilizing of the neck; securing the head; maintaining the patient in the supine position; and transferring from the stretcher with a backboard in place to the hospital bed. This patient is unconscious, and the nurse must protect the neck from any (or any further) damage. 1. Tilt the child's head back to help maintain an airway. 2. Place the child on the side to prevent aspiration. 3. Immobilize the neck, securing the head. 4. Try to rouse the child by gently shaking the shoulders.

3. Immobilize the neck, securing the head.

1. The nurse would prioritize which nursing diagnosis when caring for a patient diagnosed with a spinal cord injury? The priority nursing diagnosis is Ineffective Breathing Pattern. Spinal cord injury can result in interruption of the nerves controlling breathing muscles. 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Breathing Pattern 4. Altered Tissue Perfusion

3. Ineffective Breathing Pattern

22. A patient who has experienced an incomplete spinal cord injury (SCI) is most likely to experience which effects? Patients who have experienced an incomplete spinal cord injury will have some preservation of sensory and/or motor function below the level of injury. In these patients, there is sparing of some of the spinal cord tracts, which allows neurotransmission to occur. "S"CI = some neurotransmission of impulses. 1. Only a mild motor deficiency 2. Restoration of sensory function first 3. Some neurotransmission of impulses 4. A good prognosis for recovery

3. Some neurotransmission of impulses

28. A female patient who sustained a spinal cord injury resulting in paraplegia asks the nurse if she will ever be able to have children. How should the nurse respond? The nurse should provide valid information without promising that this particular patient will be able to bear children. 1. "You should consider adoption if you want to have a family." 2. "Sexual intercourse will not be pleasurable for you any longer." 3. "Your rehabilitation specialist will talk to you about this concern." 4. "It is possible for some women with spinal cord injuries to become pregnant and bear children."

4. "It is possible for some women with spinal cord injuries to become pregnant and bear children."

27. The nurse is preparing to discuss discharge planning with a patient who is hemiplegic as a result of a diving accident and with the patient's wife, who will be his primary caregiver. Which statement by the nurse would specifically address the needs of the caregiving wife? This wife is at high risk for caregiver role strain. Respite is essential. It is important for the nurse to make this statement so both the husband and wife recognize its importance. 1. "We will begin bowel and bladder training in 2 weeks." 2. "You will experience some role changes in your relationship." 3. "The vocational rehabilitation company will contact you next week to set up your schedule." 4. "You should plan respite time away from your husband every week."

4. "You should plan respite time away from your husband every week."

6. A hospitalized patient with a C7 cord injury asks, "Why can't I feel my legs anymore?" Which is the most appropriate action by the nurse? Spinal shock is a condition that affects almost half the people with acute spinal injury. It is characterized by a temporary loss of reflex function below the level of injury and includes the following symptomatology: 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. 1. Remind the patient of her injury and try to comfort her. 2. Call the health care 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. Explain to the patient that this could be a common, temporary problem.

10. Which nursing action is appropriate for turning a patient who sustained a spinal cord injury? Logrolling is part of standard spinal precautions. 1. This patient should not be turned. 2. Place pillows under the patient's side for support turning the turn. 3. Have the patient grasp the side rail to turn. 4. Logroll the patient.

4. Logroll the patient.

33. A patient was admitted after falling from the roof of a one-story building. Assessment reveals presence of a patellar reflex, but loss of sensation in part of both feet. The nurse would plan for which level of bowel and bladder function? This assessment indicates a lesion around L3 or L4. Bladder and bowel continence would be lost. 1. Bladder function only 2. Bowel function only 3. Intact bladder and bowel function 4. Loss of both bladder and bowel function

4. Loss of both bladder and bowel function

****15. A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and the lower part of the body. The nurse should use which medical term to correctly describe this in documentation? Tetraplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body. 1. Hemiplegia 2. Paresthesia 3. Paraplegia 4. Tetraplegia

4. Tetraplegia

24. A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the paralysis is likely to last, the nurse's response is based on which understanding? Spinal shock is a state of areflexia in which there is a loss of all motor, sensory, and reflex activity at the level of the injury and below. It is not possible to determine the severity of the injury until spinal shock has abated. 1. Spinal shock usually results in temporary paralysis. 2. There will likely be some minor improvement in the degree of paralysis. 3. Spinal shock is irreversible and the paralysis is likely to be permanent. 4. The severity of the injuries cannot be determined until the spinal shock resolves.

4. The severity of the injuries cannot be determined until the spinal shock resolves.

7. The nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Beginning with the action the nurse must first take, place the actions in the correct order. All options must be used. Standard Text: Click and drag the options below to move them up or down. 1. Check the victim's breathing. 2. Check the victim's pulse. 3. Check the victim's airway. 4. Immobilize the victim's spine. 5. Check for responsiveness.

5. Check for responsiveness. 4. Immobilize the victim's spine. 3. Check the victim's airway. 1. Check the victim's breathing. 2. Check the victim's pulse.

35. Prehospital emergency personnel have placed a patient in a head brace and on a backboard after a motor vehicle accident. The nurse would advocate for the patient to be removed from this immobilization at what time? The patient should remain immobilized until initial assessment is completed and evaluated and a treatment plan has been established. 1. As soon as the patient arrives in the emergency department 2. As soon as assessment is completed and a treatment plan is established 3. As soon as a cross-table lateral cervical spine X-ray is taken 4. As soon as the patient is admitted to the neurological intensive care unit

The patient should remain immobilized until initial assessment is completed and evaluated and a treatment plan has been established.