Spinal Cord

Incomplete SCI syndrome with: Motor paralysis, loss of proprioception, and vibratory sense below the level of injury on the same side as the injury Loss of pain and temperature sensation below the level of injury on the opposite side of the injury

Brown-Sequard Syndrome

Anterior Cord Syndrome is characterized by: a. complete loss of positional sense below the level of injury b. complete loss of motor function below the level of injury c. variable loss of motor and sensory level and maintenance of positional sense below the level of injury d. a complete disruption of all spinal tissue below the level of injury

c. variable loss of motor and sensory level and maintenance of positional sense below the level of injury

The initial suggested loading dose of IV methylprednisolone when attempting to minimize spinal injury dysfunction secondary to acute injury is? a. 5.4 mg/kg b. 10.8 mg/kg c. 20 mg/kg d. 30 mg/kg

d. 30 mg/kg over 1 hour 5.4 mg/kg per hour to continue over the next 23 hours

What is the priority nursing intervention for the management of autonomy hyperreflexia?

immediately place patient in an upright position with feet dangling to decrease BP

Injuries above what level requires immediate intubation and mechanical ventilation?

C4

Incomplete SCI Syndrome caused by hemisection of the spinal cord (gunshot, knife)

Brown-Sequard Syndrome

Two important clinical determinants of an incomplete spinal cord injury are: (choose two) a. shoulder shrug b. voluntary rectal sphincter tone c. sensation above the nipple line d. perirectal pain perception on needle stick

b. sphincter tone d. perirectal pain

During the period of spinal shock, the nurse should expect the client's bladder function to be which of the following? a. spastic b. normal c. atonic d. uncontrolled

c. atonic Will continue to fill passively unless the client is catheterized. The bladder will not go into spasms or cause uncontrolled urination.

Incomplete SCI syndrome with: Upper and lower motor neuron dynfunction Saddle anesthesia Lower extremity weakness Areflexic bladder and bowel

Conus medullaris syndrome

Incomplete SCI syndrome with: Paraplegia below the level of injury Quadraplegia for injuries higher than C7 Bilateral loss of pain and temperature Preservation of proprioception and vibratory senses below the level of injury

Anterior Cord Syndrome

Incomplete SCI syndrome located at the L1 level

Conus medullaris syndrome

Incomplete SCI Syndrome caused by hyperextension of the neck (falls and MVAs)

Central Cord Syndrome

Incomplete SCI syndrome with: Motor loss of the upper extremities Bladder dysfunction Sensory loss below the level of injury

Central cord syndrome

The rehabilitation nurse is admitting a client following a spinal cord injury. The nurse concludes that the client has developed brown-Sequard syndrome after detecting which assessment finding in the client? A. Ipsilateral motor loss above the lesion B. Contralateral loss of proprioception C. Hyperanesthesia below the level of the lesion D. Ipsilateral proprioception loss below the lesion

D. Hemisection of the anterior and posterior portions of the spinal cord results in loss of position sense on the same side of the body as the trauma, below the level of injury. Ipsilateral motor loss does not occur above the level of a spinal cord injury. Brown-Sequard syndrome does not result in contralateral loss of proprioception. Hyperanesthesia below the level of the injury is seen in anterior cord syndrome

The nurse is planning care for a client with a spinal cord injury with paraplegia. The nurse selects the nursing diagnosis of risk for injury related to spasticity of the leg muscles. The nurse plans which of the following interventions? (Select all that apply.) a. Perform range of motion to the legs. b. Use padded restraints to immobilize the limbs. c. Do not give baclofen (Lioresal) unless client seizes. d. Remove potentially harmful objects near the spastic legs. e. Provide skin care to the affected limbs.

Perform range of motion to the legs. Remove potentially harmful objects near the spastic legs. Provide skin care to the affected limbs.

A nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above T5, and BP of 162/96. The client reports a severe headache. Which of the following nursing interventions would be appropriate for this client? SATA a. elevate the head of bed 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 f. place the client in a supine position with legs elevated

a, b, d and e The client is exhibiting s/s of autonomic dysreflexia, The nurse should immediately elevate the HOB to 90 degrees and place the legs in a dependent position to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, and constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction and correct any problems. Elevated BP 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 BP, IV antihypertensives should be administered. A fan should not be used because a cold draft may trigger autonomic dysreflexia.

The nurse in the emergency department is admitting a client who fell from a two-story roof while cleaning gutters 2 days ago. The client states that he is experiencing erectile dysfunction, which is why he decided to seek treatment. The nurse suspects that this client is experiencing which of the following? a. A sacral injury at the level of S3 b. A thoracic injury at the level of T6 c. A cervical spine injury d. A lumbar spine injury

a. An injury to the sacral spine at S2-S4 is likely to cause the male client to have erectile and ejaculation issues. Cervical spine injuries are fatal at C2-C4 and cause paralysis below C4. Thoracic injury symptoms range from loss of chest movement to loss of movement of bowel and bladder. Lumbar injuries can cause issues with movement and sensation of the lower extremities.

A client with SCI is at risk for experiencing autonomic dysreflexia. The nurse would carefully monitor for which of the following manifestations? a. tachycardia b. hypotension c. severe, throbbing headache d. cyanosis of the head and neck

c. severe headache other manifestations include: flushed face and neck bradycardia severe hypertension nausea sweating nasal stuffiness blurred vision

The nurse is caring for a client with a spinal cord injury who has very little interest in eating or drinking. The nurse plans to instruct the client about risks associated with inadequate intake of food and fluids including which of the following? a. Skin breakdown c. Headaches c. Diarrhea d. Contractures of the legs

a. The client who is taking in inadequate food is at risk for developing breaks in the skin and resulting infection. Headaches and contractures are not associated with poor nutrition. Constipation, not diarrhea, is a risk associated with decreased fluids.

The nurse will be caring for a client with a spinal cord injury who has been placed in Crutchfield tongs. The nurse plans which of the following interventions for the client? a. Using a Stryker frame bed b. Calling the physician to determine if the traction is appropriate c. Removing the weights during repositioning d. Leaving assessment of the weights to the physician

a. The nurse would have a Stryker bed available for the client with Crutchfield tongs. The nurse never removes weights applied to Crutchfield tongs. The nurse is able to evaluate that the weights are hanging free and that the amount of weights ordered has been correctly applied.

A nurse is caring for a client who experienced a cervical spine injury 3 months ago. Which of the following types of bladder management methods should the nurse use for this client? a. condom catheter b. intermittent urinary cauterization c. Crede's method d. indwelling urinary catheter

a. a client who has a cervical spinal cord injury will also have an upper motor neuron injury, which is manifested by a spastic bladder. Because the bladder will empty on its own, a condom catheter is an appropriate method and it's noninvasive.

The nurse is planning to teach the client with SCI and intermittent NG suctioning about interventions to protect her integumentary system. The nurse should tell the client to: a. eat enough calories to maintain desired weight b. stay in cool environments to avoid sweating c. stay in warm environments to avoid chilling d. eat low-sodium foods to avoid edema

a. calories To decrease the rate of muscle atrophy and prevent skin breakdown and infection. The client with SCI does not have poikilothermy, the ability to adjust body temperature to the environment. The client should add additional clothes ore coverage below the level of transection in cool environments. The client does not sweat below the level of transection and should be sensitive to the possibility of overheating in hot climates. The client with intermittent NG suctioning is at risk for development of metabolic alkalosis and an electrolyte imbalance that leads to decreased tissue perfusion; therefore, the clients needs to increase NA and K, not decrease NA

When assessing the client with a cord transection above T5 for possible complications, which of the following should the nurse expect as least likely to occur? a. diarrhea b. paralytic ileus c. stress ulcers d. intra-abdomina bleeding

a. diarrhea constipation is more likely

A central cord syndrome is characterized by: choose two a. disproportionately greater motor impairment of the upper extremities b. disproportionately greater motor impairment of the lower extremities c. variable sensory loss below the level of injury d. loss of positional sense below the level of injury

a. greater motor impairment of the upper ext. c. sensory loss below the level of injury

Brown-Sequard Syndrome is characterized by: choose two a. motor loss on the same side as the injury b. motor loss on the opposite side as the injury c. sensory loss on the same side as the injury d. sensory loss on the opposite side as the injury

a. motor loss on same side d. sensory loss on the opposite side

A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or bladder. Which of the following should be the nurses's highest priority? a. prevention of further damage to the spinal cord b. prevention of contractors of the lower extremities c. prevention of skin breakdown of areas that lack sensation d. prevention of postural hypotension when placing the client in a wheelchair

a. the greatest risk to the client during the acute phase of a SCI is further damage tot he spinal cord Therefore, when planning care, the priority should be the prevention of further damage tot he spinal cord by administration of corticosteriods, minimizing movement of the client until spinal stabilization is accomplished through either traction or surgery, and adequate oxygenation of the client to decrease ischemia of the spinal cord.

A nurse is assessing a client for changes in the LOC using the Glasgow Coma Scale. The client opens his eyes when spoken to, speaks incoherently, and moves his extremities when pain is applied. Which of the following is the correct scoring by the nurse using the scale that indicates the client has a moderate head injury? a. E2+ V3 + M5 = 10 b. E3 + V4 + M4 = 11 c. E4 + V5 + M6 = 15 d. E2 + V2 + M4 = 8

b.

The family members of a client with a spinal cord injury tell the nurse that the client becomes angry whenever someone tries to help or participate in care. The nurse's best response is to: a. Tell the client the family will not visit anymore. b. Assist the family to understand the source of the client's anger. c. Ask the client to stop acting out with the family. d. Ask the family to refrain from giving care.

b. The nurse helps the family to understand and acknowledge the client's anger. The family would then make the choice about whether or not to continue to participate in the client's care. Asking the client to stop the anger is not reasonable. The client is grieving a significant loss and needs to be allowed to work through the issues. Telling the client that the family will not visit is threatening and inappropriate.

A nurse is caring for a client who experienced a traumatic head injury and has an intraventricular catheter for ICP monitoring. The nurse should monitor the client for which of the following complications related to the ventriculostomy? a. headache b. infection c. aphasia d. hypertension

b. infection is a complication. Strict asepsis should be used to avoid this life-threatening condition, which may result in meningitis. All others should be monitored, but not the priority.

A nurse is caring for a client post-lumbar puncture who reports a throbbing headache when sitting upright for meals. Which of the following are appropriate actions by the nurse? select all a. use the Glasgow Coma Scale b. assist the client to eat meals while laying flat in bed c. administer an opioid medication d. encourage client to increase fluid intake e. place client in a "cannonball" position

b. prone position c. opioid d. fluid a. GCS is used to assess LOC d. cannonball position is used for the LP

A nurse is caring for a client with a spinal cord injury who reports a severe headache and is sweating profusely. Vital signs include BP of 220/110, with an apical HR of 54/min. Which of the following actions should the nurse take first? a. notify the provider b. sit the client upright in bed c. check the client's urinary catheter for a blockage d. administer antihypertensive medications

b. the greatest risk to the client is a CVA (stroke) secondary to elevated BP. The first action by the nurse is to elevate the head of the bed until the client is in an upright position. This will lower the blood pressure secondary to postural hypotension.

When the client has a cord transection at T4, which of the following is the primary focus of the nursing assessment? a. renal status b. vascular status c. GI function d. biliary function

b. vascular status The sympathetic feedback system is lost and the client is at risk for hypotension and bradycardia

A nurse is conducting teaching for a client with a spinal cord injury who is being discharged with halo traction. The nurse concludes that further instruction is necessary upon learning that the client intends to: a. Monitor balance carefully. b. Care for the skin under the vest daily. c. Drive in the daytime only. d. Drink with a straw.

c. The client with halo traction cannot drive because the traction limits mobility and impairs range of vision. The client should drink with a straw and cut foods into small pieces to facilitate chewing. The halo can cause imbalance, so the client is cautioned to monitor balance carefully. The client is taught to care for the skin under the vest.

A 20-year-old client who is engaged to be married is injured in a hit-and-run accident. The spinal cord injury leaves the client paralyzed from the waist down. When planning care for this client, the nurse expects to address which of the following? a. Anger b. Fatigue c. Grieving d. Bargaining

c. This client is just beginning adult life and will no longer be able to complete developmental tasks as planned, such as raising a family, so the nurse expects this client to grieve the loss of life as previously anticipated. Anger and bargaining are two facets of grieving and the client will be faced with the whole grieving process, not just parts. Fatigue may or may not be an issue for this client.

Administration of large doses of methylprednisolone can result in: choose two a. hypoglycemia b. hypothermia c. hyperglycemia d. gastric bleeding

c. hyperglycemia d. gastric bleeding

The client with a SCI asks the nurse why the dietician has recommended to decrease the total fail intake of calcium. Which of the following responses by the nurse would provide the most accurate information? a. Excessive intake of fairy products makes constipation more common b. Immobility increases calcium absorption from the intestine c. Lack of weight bearing causes demineralization of the long bones d. Dairy products likely will contribute to weight gain.

c. lack of weight bearing causes demineralization of the long bones causing kidney stones

The extent of injury to spinal neurological tissue is best identified by: a. clinical exam b. CT cord scan c. plain spinal x-rays d. MRI

d. MRI

A nurse is caring for a client who experienced a cervical spine injury 24 hours ago. Which of the following types of prescribed medications should the nurse clarify with the provider. a. glucocorticoids b. plasma expanders c. H2 antagonists d. muscle relaxants

d. The client will still be in spinal shock 24 hours following the injury. The client will not experience muscle spasms until after the spinal shock as resolved, making muscle relaxants unnecessary at this time. All other medications are appropriate

After one month of therapy, the client in spinal shock begins to experience muscle spasms in his legs. He calls the nurse in excitement to report the movement. Which of the following responses by the nurse would be the most accurate? a. these movements indicate that the damaged nerves are healing b. this is a good sign. Keep trying to move all the affected muscles c. the return of movement means that eventually you will walk again d. the movements occur from muscle reflexes that can't be initiated or controlled by the brain.

d. The movements occur from muscle reflexes and cannot be initiated or controlled by the brain. After the period of spinal shock, the muscles gradually become spastic owing to an increased sensitivity of the lower motor neurons. It is an expected occurrence and does not indicate that healing is taking place.

The nurse provides care for a client who was placed in a halo brace within the last 24 hours because of a spinal cord injury. Which of the following is the first priority of the nurse? a. Loosen connections on the vest to observe the skin. b. Ask how the client is able to reposition in bed. c. Encourage active range of motion to lower extremities. d. Examine the pin sites.

d. The nurse would want to observe pin sites for redness, edema, and drainage, and would want to assure that the vest fits snugly. Following the nursing process, data collection would precede implementation of the actions in the other choices.

Which of the following should the nurse use as the best method to assess for the development of DVT in a client with a SCI? a. homans' sign b. pain c. tenderness d. leg girth

d. leg girth Patient can't feel A, B, and C

A nurse is caring for a client who has a C4 spinal cord injury. Which of the following should the nurse recognize the client as being at the greatest risk for? a. neurogenic shock b. paralytic ileus c. stress ulcer d. respiratory compromise

d. using the ACB priority-setting, the greatest risk to the client is respiratory compromise secondary to involvement of the phrenic nerve. Maintenance of an airway and provision of ventilatory support as needed is the priority intervention