PrepU ch63

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Autonomic dysreflexia Spinal shock Concussion Contusion

Autonomic dysreflexia

A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5

C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Sports-related injuries Falls Motor vehicle crashes Acts of violence

Motor vehicle crashes

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? Paralysis Sciatic nerve pain Herniation Paresthesia

Paresthesia

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Raise the head of the bed and place the patient in a sitting position. Examine the rectum for a fecal mass. Examine the skin for any area of pressure or irritation. Empty the bladder immediately.

Raise the head of the bed and place the patient in a sitting position.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? Akathisia Ataxia Myoclonus Spasticity

Spasticity

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? S2 T10 T6 L4

T6

Which are risk factors for spinal cord injury (SCI)? Select all that apply. Female gender Young age Alcohol use Drug abuse European American ethnicity

Young age Alcohol use Drug abuse

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? laceration skull fracture concussion contusion

concussion

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? Place the patient in a sitting position. Call the physician. Assess the patient for a full bladder. Assess the patient for a fecal impaction.

Place the patient in a sitting position.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? Voiding Placing the client in a sitting position Placing a blanket over the client Diarrhea

Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Areflexia Autonomic dysreflexia Paraplegia Tetraplegia

Autonomic dysreflexia

A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient? Bradycardia and hypertension Tachycardia and hypertension Tachycardia and hypotension Bradycardia and hypotension

Bradycardia and hypertension

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Cane The patient will be able to ambulate independently. Voice or sip-n-puff controlled electric wheelchair Electric or modified manual wheelchair, needs transfer assistance

The patient will be able to ambulate independently.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? Traction with weights and pulleys Cervical collar Cast Turning frame

Traction with weights and pulleys

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? To increase cerebral perfusion pressure Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To prevent secondary brain injury So that the patient will not have a respiratory arrest

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord