SCI NCLEX Review
The nurse on the rehabilitation unit is caring for the following clients. Which client should the nurse assess first after receiving the change-of-shift report? 1. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. 2. The client with an L4 SCI who is crying and very upset about being discharged home. 3. The client with an L2 SCI who is complaining of a headache and feeling very hot. 4. The client with a T4 SCI who is unable to move the lower extremities.
1 This client has signs/symptoms of a respiratory complication and should be assessed first.
The home health nurse is caring for a 28-year-old client with a T10 SCI who says, "I can't do anything. Why am I so worthless?" Which statement by the nurse wouldbe the most therapeutic? 1. "This must be very hard for you. You're feeling worthless?" 2. "You shouldn't feel worthless—you are still alive." 3. "Why do you feel worthless? You still have the use of your arms." 4. "If you attended a work rehab program you wouldn't feel worthless."
1 Therapeutic communication addresses the client's feelings and attempts to allow the client to verbalize feelings;the nurse should be a therapeutic listener
The nurse in the neurointensive care unit is caring for a client with a new C6 SCI who is breathing independently. Which nursing interventions should be implemented? Select all that apply. 1. Monitor the pulse oximetry reading. 2. Provide pureed foods six (6) times a day. 3. Encourage coughing and deep breathing. 4. Assess for autonomic dysreflexia. 5. Administer intravenous corticosteroids.
1 3 5 Oxygen is administered initially to prevent hypoxemia, which can worsen the spinal cord injury; therefore, thenurse should determine how muchoxygen is reaching the periphery. Breathing exercises are supervised by the nurse to increase the strengthand endurance of inspiratory muscles, especially those of the diaphragm Corticosteroids are administered to decrease inflammation, which will decrease edema, and help preventedema from ascending up the spinalcord, causing breathing difficulties
In assessing a client with a T12 SCI, which clinical manifestations would the nurseexpect to find to support the diagnosis of spinal shock? 1. No reflex activity below the waist. 2. Inability to move upper extremities. 3. Complaints of a pounding headache. 4. Hypotension and bradycardia.
1. Spinal shock associated with SC Irepresents a sudden depression of reflex activity below the level of the injury. T12 is just above the waist;therefore, no reflex activity below the waist would be expected
The rehabilitation nurse caring for the client with an L1 SCI is developing the nursing care plan. Which intervention should the nurse implement? 1. Keep oxygen via nasal cannula on at all times. 2. Administer low-dose subcutaneous anticoagulants. 3. Perform active lower extremity ROM exercises. 4. Refer to a speech therapist for ventilator-assisted speech.
2 Deep vein thrombosis (DVT) is a potential complication of immobility,which can occur because the clientcannot move the lower extremities as a result of the L1 SCI. Low-dose anticoagulation therapy (Lovenox)helps prevent blood from coagulating,thereby preventing DVTs.
The client with a cervical fracture is being discharged in a halo device. Which teaching instruction should the nurse discuss with the client? 1. Discuss how to correctly remove the insertion pins. 2. Instruct the client to report reddened or irritated skin areas. 3. Inform the client that the vest liner cannot be changed. 4. Encourage the client to remain in the recliner as much as possible.
2 Reddened areas, especially under thebrace, must be reported to the HCPbecause pressure ulcers can occurwhen wearing this appliance for an extended period.
The 34-year-old male client with an SCI is sharing with the nurse that he is worried about finding employment after being discharged from the rehabilitation unit.Which intervention should the nurse implement? 1. Refer the client to the American Spinal Cord Injury Association (ASIA). 2. Refer the client to the state rehabilitation commission. 3. Ask the social worker about applying for disability. 4. Suggest that the client talk with his significant other about this concern.
2 The rehabilitation commission of each state will help evaluate and determine if the client can receive training or education for another occupation after injury.
The client with a C6 SCI is admitted to the emergency department complaining of asevere pounding headache and has a BP of 180/110. Which intervention should theemergency department nurse implement? 1. Keep the client flat in bed. 2. Dim the lights in the room .3. Assess for bladder distention. 4. Administer a narcotic analgesic.
3 This is an acute emergency caused by exaggerated autonomic responses to stimuli and only occurs after spinal shock has resolved in the client with a spinal cord injury above T6. The most common cause is a full bladder.
Which nursing task would be most appropriate for the nurse to delegate to the unlicensed assistive personnel? 1. Teach Credé's maneuver to the client needing to void. 2. Administer the tube feeding to the client who is quadriplegic. 3. Assist with bowel training by placing the client on the bedside commode. 4. Observe the client demonstrating self-catheterization technique.
3 The assistant can place the client on the bedside commode as part of bowel training; the nurse is responsible for the training but can delegate this task
The nurse arrives at the site of a one-car motor-vehicle accident and stops to render aid. The driver of the car is unconscious. After stabilizing the client's cervical spine,which action should the nurse take next? 1. Carefully remove the driver from the car. 2. Assess the client's pupils for reaction. 3. Assess the client's airway. 4. Attempt to wake the client up by shaking him.
3 The nurse must maintain a patent air-way. Airway is the first step in resuscitation. 1. The nurse should stabilize the client's neck prior to removal from the car. 2. The nurse must stabilize the client's neck before doing any further assessment. Most nurses don't carry penlights, and the client's pupil reaction can be determined after stabilization. 4. Shaking the patient could cause further damage, possibly l
The intensive care nurse is caring for a client with a T1 SCI. When the nurse elevates the head of the bed 30 degrees, the client complains of light headedness and dizziness. The client's vital signs are T 99.2 ̊F, P 98, R 24, and BP 84/40. Which action should the nurse implement? 1. Notify the health-care provider ASAP. 2. Calm the client down by talking therapeutically. 3. Increase the IV rate by 50 mL/hour. 4. Lower the head of the bed immediately.
4 For the first two (2) weeks after an SCI above T7, the blood pressure tends to be unstable and low; slight elevations of the head of the bed can cause profound hypotension; therefore, the nurse should lower the head of the bed immediately.
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A Quadriplegia with gross arm movement and diaphragmatic breathing B Quadriplegia and loss of respiratory function C Paraplegia with intercostal muscle loss D Loss of bowel and bladder control
A A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A Elevate the HOB to 90 degrees B Loosen constrictive clothing C Use a fan to reduce diaphoresis D Assess for bladder distention and bowel impaction E Administer antihypertensive medication
A B D E The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia
The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A A flattened abdomen B Hematest positive nasogastric tube drainage C Hyperactive bowel sounds D A history of diarrhea
B After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A To hasten wound healing B To immobilize the cervical spine C To prevent autonomic dysreflexia D To hold bony fragments of the skull together
B Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A Decreased urine output or oliguria B Hypertension and bradycardia C Respiratory depression D Symptoms of shock
B Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A Insert an indwelling urinary catheter to straight drainage B Schedule intermittent catheterization every 2 to 4 hours C Perform a straight catheterization every 8 hours while awake D Perform Crede's maneuver to the lower abdomen before the client voids.
B Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede's maneuver is not used on people with spinal cord injury.
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A Absence of pain sensation in chest B Spasticity C Spontaneous respirations D Urinary continence
B Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A Strict adherence to a bowel retraining program B Limiting bladder catheterization to once every 12 hours C Keeping the linen wrinkle-free under the client D Preventing unnecessary pressure on the lower limbs
B The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A A client with a brain injury B A client with a herniated nucleus pulposus C A client with a high cervical spine injury DA client with a stroke
C Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.
A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A Acetazolamide (Diamox) B Furosemide (Lasix) C Methylprednisolone (Solu-Medrol) D Sodium Bicarbonate
C High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance.
A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A By inserting a nasopharyngeal airway B By inserting a oropharyngeal airway C By performing a jaw-thrust maneuver D By performing the head-tilt, chin-lift maneuver
C If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A Autonomic dysreflexia B Hypervolemia C Neurogenic shock D Sepsis
C Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.
The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A Monitoring vital signs before and during position changes B Using vasopressor medications as prescribed C Moving the client quickly as one unit D Applying Teds or compression stockings.
C Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client's position slowly. Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A Positive reflexes B Hyperreflexia C Inability to elicit a Babinski's reflex D Reflex emptying of the bladder
C Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A Bladder distension B Neurological deficit C pulse ox readings D The client's feelings about the injury
C After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A Autonomic dysreflexia B Hemorrhagic shock C Neurogenic shock D Pulmonary embolism
C Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? A "Clean the meatus from back to front." B "Measure the quantity of urine." C "Gently rotate the catheter during removal." D "Clean the meatus with soap and water."
D Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn't necessary to measure the urine. The catheter doesn't need to be rotated during removal.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A Elevate the client's legs B Put the client flat in bed C Put the client in the Trendelenburg's position D Put the client in the high-Fowler's position
D Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Elevating the client's legs, putting the client flat in bed, or putting the bed in the Trendelenburg's position places the client in positions that improve cerebral blood flow, worsening hypertension.
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A Keeping the client on a stretcher B Logrolling the client on a firm mattress C Logrolling the client on a soft mattress D Placing the client on a Stryker frame
D Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
A client with a C6 spinal injury would most likely have which of the following symptoms? A: Aphasia B: Hemiparesis C:Paraplegia D: Tetraplegia
D Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? A Absent corneal reflex B Decerebrate posturing C Movement of only the right or left half of the body D The need for mechanical ventilation
D The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A Place the client flat in bed B Assess patency of the indwelling urinary catheter C Give one SL nitroglycerin tablet D raise the head of the bed immediately to 90 degrees
D Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.
