Evolve Questions SCI
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? 1 Urine retention 2 Emotional stress 3 Smoking cigarettes 4 People with upper respiratory infections
1 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.
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? 1 Damage to the central spinal cord 2 Damage to the anterior spinal artery 3 Damage to the posterior spinal artery 4 Damage to one-half of the spinal cord
2 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.
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. 1 Gastroenteritis 2 Signs of any infection 3 Signs of any internal bleeding 4 Any history of recent surgeries 5 Signs of any respiratory distress
3, 4 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.
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? 1 C1-3 2 C4 3 C5 4 C6
1 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.
Which intervention should the nurse perform in the acute care of a patient with autonomic dysreflexia? 1 Urinary catheterization 2 Administration of benzodiazepines 3 Suctioning of the patient's upper airway 4 Placement of the patient in the Trendelenburg position
1 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.
The patient with a spinal cord injury (SCI) is admitted to the intensive care unit. What does the nurse know about this injury? 1 Differences in drug metabolism are related to the level and completeness of the injury. 2 Methylprednisolone (MP) needs to be given intravenously within the first few hours of injury. 3 Low-molecular-weight heparin is not used because of the increased risk of bleeding and hemorrhage. 4 Vasopressor agents are contraindicated, because they can reduce the blood flow to vital organs.
1 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.
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. 1 Use special mattresses to reduce pressure. 2 Use wheelchair cushions to reduce pressure. 3 Use pillows to protect bony prominences when in bed. 4 If in a wheelchair, lift oneself up and shift weight every two to four hours. 5 If in bed, change positions using a regular turning schedule of six hours.
1, 2, 3 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.
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. 1 Independent self-care is possible. 2 Independent wheelchair mobility is possible. 3 Patient may be able to drive with hand controls. 4 Patient will be able to climb stairs independently. 5 Patient will be able to have effective coughing ability.
1, 2, 3 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. 1 Provide adequate time to eat. 2 Encourage intake of dietary fiber. 3 Keep a calorie count of the food taken. 4 Provide a pleasant eating environment. 5 Provide a low-protein and low-calorie diet. 6 Feed the patient only hospital-cooked food
1, 2, 3, 4 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.
n 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. 1 Bowel incontinence 2 Urinary incontinence 3 Difficulty in breathing 4 Hypotonicity of the lower limbs 5 Hypotonicity of the upper limbs
1, 2, 4 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. 1 Insert a nasogastric tube. 2 Evaluate swallowing before starting oral feeding. 3 Prescribe a low-protein and low-carbohydrate diet. 4 If oral feeding is not possible, enteral nutrition must be provided. 5 Gradually introduce oral food and fluids, irrespective of bowel sounds.
1, 2, 4 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 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. 1 Cleanse the catheter regularly. 2 Always keep the urine bag above the waist. 3 Limit water intake to less than a liter a day. 4 Check for the presence of any folds or kinks in the catheter tube. 5 Check for signs of urinary tract infection (fever, change in odor or color of urine).
1, 4, 5 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. 1 These spasms can occur as a result of a variety of stimuli. 2 This occurs due to hyperexcitability of the upper motor neuron. 3 These spasms indicate improvement in the condition of the patient. 4 Such reflexes could be positively used for bowel and bladder retraining. 5 This occurs due to a break in the link between the upper and lower motor neuron interaction.
1, 4, 5 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. 1 Administer oxygen. 2 Administer steroids. 3 Administer antibiotic drugs. 4 Perform tracheal suctioning. 5 Use assisted coughing techniques.
1, 4, 5 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.
e 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? 1 Central cord syndrome 2 Spinal shock syndrome 3 Anterior cord syndrome 4 Brown-Séquard syndrome
2 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 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. 1 The injury does not cause amenorrhea. 2 Precautions for unplanned pregnancy are necessary. 3 The patient does have the capacity to become pregnant. 4 Erotic and sexual thoughts may not cause vaginal lubrication to take place. 5 Fatal complications like autonomic dysreflexia could be associated with pregnancy
2, 3, 4, 5 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. 1 Show sympathy towards the patient. 2 Encourage the patient to set daily goals. 3 Encourage the patient to participate in care. 4 Explain the injury using written teaching material. 5 Teach the patient what to expect during the rehabilitation period.
2, 3, 5 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 patient with spinal cord injury has begun to get stress ulcers. What nursing interventions should be performed for this patient? Select all that apply. 1 Withhold antacids. 2 Check stools for blood. 3 Motivate the patient and provide a stress-free environment. 4 Obtain prescriptions for increased dosage of corticosteroids. 5 Administer proton pump inhibitors for prophylaxis as prescribed.
2, 3, 5 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 (H2)-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. 1 Male fertility will not be affected by the injury. 2 A reflex erection could be easily elicited in the patient. 3 The patient may have erectile dysfunction that can be treated. 4 The patient's ability to have psychogenic erections is not affected. 5 Vacuum suction devices help in improving blood flow to the penis.
2, 3, 5 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 with spinal cord injury has to be catheterized. Which nursing interventions will help to prevent urinary tract infection (UTI)? Select all that apply. 1 Empty the urine bag whenever it is 25 percent filled. 2 Ensure regular and complete drainage of the bladder. 3 Start intermittent catheterization once the patient is stabilized. 4 Maintain the urine drainage bag above the level of the bladder. 5 Cleanse the patient's genitalia using antiseptic before placing the catheter.
2, 3, 5 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 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. 1 Lower the head of the bed. 2 Monitor blood pressure regularly. 3 Make the patient lie flat on the bed. 4 Notify the primary health care provider. 5 Check for the presence of bowel impaction. 6 Remove the kink in the catheter and drain the bladder
2, 4, 5, 6 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. 1 The patient has an absence of bowel sounds. 2 There is excess gastric distention, and the stomach is hard. 3 The patient is constipated and is passing hard stools with straining. 4 The sensation of a full bowel is perceived by the patient, and fecal incontinence is present. 5 The sensation of a full bowel is not perceived by the patient, and fecal incontinence is present.
2, 5 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. 1 Digoxin 2 Atropine 3 Metoclopramide 4 Vasodilator drugs 5 Vasopressor drugs
2, 5 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.
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. 1 Involuntary stool 2 Severe drop in blood pressure 3 Sudden onset of severe headache 4 Sweating above the level of the SCI 5 Flushed face and chest above the level of the SCI
3, 4, 5 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.
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? 1 Central cord syndrome 2 Anterior cord syndrome 3 Cauda equina syndrome 4 Brown-Séquard syndrome
4 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.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis has the highest priority ? 1 Risk for impairment of tissue integrity caused by paralysis 2 Altered patterns of urinary elimination caused by tetraplegia 3 Altered family and individual coping caused by the extent of trauma 4 Ineffective airway clearance caused by high cervical spinal cord injury
4 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).
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? 1 "I want to be rehabilitated for my daughter's wedding in two weeks." 2 "Rehabilitation will be more work done by me alone to try to get better." 3 "I will be able to do all my normal activities after I go through rehabilitation." 4 "With rehabilitation, I will be able to function at my highest level of wellness."
4 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. 1 Nitrates 2 Diuretics 3 Beta blockers 4 Anticoagulants 5 Intravenous fluids
4, 5 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.