Chapter 60, Nursing Management: Spinal Cord and Peripheral Nerve Problems: Spinal Cord Problems

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 Emotional stress Smoking cigarettes People with upper respiratory infections

Urine retention

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. Drink more milk Use oral laxatives every day Eat 20 to 30 g of fiber per day Drink 1800 to 2800 mL of water or juice Establish bowel evacuation time at bedtime

Eat 20 to 30 g of fiber per day Drink 1800 to 2800 mL of water or juice

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. Male fertility will not be affected by the injury. A reflex erection could be easily elicited in the patient. The patient may have erectile dysfunction that can be treated. The patient's ability to have psychogenic erections is not affected. Vacuum suction devices help in improving blood flow to the penis.

A reflex erection could be easily elicited in the patient. The patient may have erectile dysfunction that can be treated Vacuum suction devices help in improving blood flow to the penis.

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 feed self with setup Ability to drive an electric wheelchair Attendant care required for 10 hours in a day Independent computer use with adaptive equipment

Ability to drive an electric wheelchair

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. Administer steroids. Administer antibiotic drugs. Perform tracheal suctioning. Use assisted coughing techniques.

Administer oxygen. Perform tracheal suctioning. Use assisted coughing techniques.

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. Nitrates Diuretics Beta blockers Anticoagulants Intravenous fluids

Anticoagulants Intravenous fluids

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. Assess thighs and calves for signs of DVT. Administer prophylactic low-dose low-molecular-weight heparin. Obtain venous Doppler reports before applying compression stockings. Perform passive movements with the patient once deep vein thrombosis is established. Ensure that the patient wears compression stockings continuously throughout the day.

Assess thighs and calves for signs of DVT. Administer prophylactic low-dose low-molecular-weight heparin. Obtain venous Doppler reports before applying compression stockings.

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. Digoxin Atropine Metoclopramide Vasodilator drugs Vasopressor drugs

Atropine Vasopressor drugs

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 Difficulty in breathing Hypotonicity of the lower limbs Hypotonicity of the upper limbs

Bowel incontinence Urinary incontinence Hypotonicity of the lower limbs

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

Bradycardia

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

Bradycardia Hypotension Peripheral vasodilation

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? Central cord syndrome Anterior cord syndrome Posterior cord syndrome Brown-Séquard syndrome

Brown-Séquard 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 based on the assessment data? Central cord syndrome Anterior cord syndrome Cauda equina syndrome Brown-Séquard syndrome

Brown-Séquard syndrome

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? C1-C3 C5-T6 T1-L2 Above T5

C1-C3

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? Has a poor prognosis Can affect any age group Can occur on both sides of the face. Affects more than 100,000 people every year

Can affect any age group

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. Withhold antacids. Check stools for blood. Motivate the patient and provide a stress-free environment. Obtain prescriptions for increased dosage of corticosteroids. Administer proton pump inhibitors for prophylaxis as prescribed.

Check stools for blood. Motivate the patient and provide a stress-free environment. Administer proton pump inhibitors for prophylaxis as prescribed.

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. Check the nutritional status of the patient. Check the patency of the urinary catheter. Change the position of the patient every six hours. Avoid lifting the patient when changing the position. Check bony prominences for signs of pressure sores.

Check the nutritional status of the patient. Check the patency of the urinary catheter. Check bony prominences for signs of pressure sores.

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

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 central spinal cord Damage to the anterior spinal artery Damage to the posterior spinal artery Damage to one-half of the spinal cord

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. Lower the systolic blood pressure. Control elevated serum glucose levels. Improve muscular strength in the lower extremities.

Decrease tumor-related edema.

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. Depression Abnormal taste sensation Difficulty in swallowing food Hurried feeding by the nurse Boredom due to institutional food Continuous bed rest and weakness

Depression Hurried feeding by the nurse Boredom due to institutional food Continuous bed rest and weakness

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. Methylprednisolone (MP) needs to be given intravenously within the first few hours of injury. Low-molecular-weight heparin is not used because of the increased risk of bleeding and hemorrhage. Vasopressor agents are contraindicated, because they can reduce the blood flow to vital organs.

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? Stab wound Diving accident Gunshot wound Torn spinal cord

Diving accident

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. Show sympathy towards the patient. Encourage the patient to set daily goals. Encourage the patient to participate in care. Explain the injury using written teaching material. Teach the patient what to expect during the rehabilitation period.

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 interventions will help to prevent urinary tract infection (UTI)? Select all that apply. Empty the urine bag whenever it is 25 percent filled. Ensure regular and complete drainage of the bladder. Start intermittent catheterization once the patient is stabilized. Maintain the urine drainage bag above the level of the bladder. Cleanse the patient's genitalia using antiseptic before placing the catheter.

Ensure regular and complete drainage of the bladder. Start intermittent catheterization once the patient is stabilized. Cleanse the patient's genitalia using antiseptic 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. Avoid "logrolling" of the patient. Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Use a soft cervical collar to stabilize the cervical spine. Use a firm backboard to prevent any spinal movement.

Ensure that the patient's body is correctly aligned. Use a sternal-occipital-mandibular immobilizer brace. Use a firm backboard to prevent any spinal movement.

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? Dietary habits Exercise practices Psychosocial status Present medication list

Exercise practices

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. Teach the Valsalva maneuver. Explain the use of stool softeners. Advise the patient to eat a high-fiber diet. Advise the patient to limit fluids in the diet. Teach the patient how to use suppositories for evacuation. Teach the patient to perform digital stimulation of the rectum.

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.

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 Irregular respirations and shortness of breath Decreased level of consciousness or hallucinations Abdominal distention and absence of bowel sounds

Headache and rising blood pressure

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 spicy food to improve taste. Include two servings from the milk group. Eat three well-balanced meals each day. Include beans in the diet to increase fiber intake. Include two or more servings from the meat group.

Include two servings from the milk group. Eat three well-balanced meals each day Include two or more servings from the meat group.

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. Independent self-care is possible. Independent wheelchair mobility is possible. Patient may be able to drive with hand controls. Patient will be able to climb stairs independently. Patient will be able to have effective coughing ability.

Independent self-care is possible. Independent wheelchair mobility is possible. Patient may be able to drive with hand controls.

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. Prescribe a low-protein and low-carbohydrate diet. If oral feeding is not possible, enteral nutrition must be provided. Gradually introduce oral food and fluids, irrespective of bowel sounds.

Insert a nasogastric tube. Evaluate swallowing before starting oral feeding. If oral feeding is not possible, enteral nutrition must be provided.

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. It helps to find the exact location of injury. It helps to diagnose deep vein thrombosis (DVT). It helps to assess changes in the neurologic tissue. It helps to find the degree of spinal canal compromise. It helps to find the presence of any damage to the spinal or vertebral arteries.

It helps to find the exact location of injury. It helps to find the degree of spinal canal compromise.

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 Cervical vertebra 4 Cervical vertebra 6 Thoracic vertebra 6

Lumbar vertebra 1

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

MRI

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? Monitoring vital signs Maintaining a patent airway Maintaining proper body alignment Turning and repositioning the patient every two hours

Maintaining a patent airway

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. Lower the head of the bed. Monitor blood pressure regularly. Make the patient lie flat on the bed. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.

Monitor blood pressure regularly. Notify the primary health care provider. Check for the presence of bowel impaction. Remove the kink in the catheter and drain the bladder.

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. The injury does not cause amenorrhea. 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.

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. Provide a low-protein and low-calorie diet. Feed the patient only hospital-cooked food

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. Gastroenteritis Signs of any infection Signs of any internal bleeding Any history of recent surgeries Signs of any respiratory distress

Signs of any internal bleeding Any history of recent surgeries

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? Prone position Sitting position Supine position Standing position

Sitting position

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

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? Central cord syndrome Spinal shock syndrome Anterior cord syndrome Brown-Séquard syndrome

Spinal shock syndrome

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. Involuntary stool Severe drop in blood pressure Sudden onset of severe headache Sweating above the level of the SCI Flushed face and chest above the level of the SCI

Sudden onset of severe headache Sweating above the level of the SCI Flushed face and chest above the level of the SCI

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. The patient has an absence of bowel sounds. There is excess gastric distention, and the stomach is hard. The patient is constipated and is passing hard stools with straining. The sensation of a full bowel is perceived by the patient, and fecal incontinence is present. The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.

There is excess gastric distention, and the stomach is hard. The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.

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. There is fluid overload in the lungs. There is severe constriction of airways. The nerve that controls breathing is damaged. The muscle responsible for breathing is paralyzed. There is accumulation of secretions in the lungs, which has caused collapse of the lungs.

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. Blood pressure and heart rate have increased. Blood vessels in the extremities have constricted. 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.

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.

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. These spasms can occur as a result of a variety of stimuli. This occurs due to hyperexcitability of the upper motor neuron. These spasms indicate improvement in the condition of the patient. Such reflexes could be positively used for bowel and bladder retraining. This occurs due to a break in the link between the upper and lower motor neuron interaction.

These spasms can occur as a result of a variety of stimuli. Such reflexes could be positively used for bowel and bladder retraining. This occurs due to a break in the link between the upper and lower motor neuron interaction.

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. Apply massage to areas with sustained redness. Follow a diet high in vitamins and low in protein. Inspect all skin areas on a daily basis using a mirror as necessary.

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. If in a wheelchair, lift oneself up and shift weight every two to four hours. If in bed, change positions using a regular turning schedule of six hours.

Use special mattresses to reduce pressure. Use wheelchair cushions to reduce pressure. Use pillows to protect bony prominences when in bed.

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. pH = 7.27 PaO 2 = 80 mm Hg PaCO 2= 55 mm Hg PaHCO 3 = 26 mm Hg

pH = 7.27 PaCO 2= 55 mm Hg