Deck 20: Acute Spinal Cord Injury

Question 1

What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Assess motor and sensory function every shift.
B)Have the patient hold onto the halo struts during turns and repositioning.
C)Keep the pins and traction bars slightly loose to prevent pressure ulcers.
D)Tape a halo vest wrench to the front of the vest.
E)Use a moist cloth to clean the skin under the vest.

Answer 1

Tape a halo vest wrench to the front of the vest.
Use a moist cloth to clean the skin under the vest.

Question 2

A patient is diagnosed with central cord syndrome.Which assessment finding would the nurse anticipate from this injury?

A)Complete paralysis of lower extremities
B)Loss of bladder and bowel function
C)Motor function intact in upper extremities
D)Variable motor function in lower extremities

Answer 2

Variable motor function in lower extremities

Question 3

A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clamshell brace.How would the nurse explain the purpose of this brace?

A)"Wearing this brace will eliminate the need for further surgery."
B)"You need to wear this device to support your stabilization."
C)"This brace will maximize your range of motion."
D)"You need to wear this brace to protect your surgical incision."

Answer 3

"You need to wear this device to support your stabilization."

Question 4

A patient diagnosed with several fractured vertebra is having surgical stabilization.The nurse would reinforce which information about this surgery?

A)"You will be required to wear a hard cervical collar for several months after the surgery."
B)"After surgery you will be fitted for a halo device."
C)"The fusion generally requires insertion of rods to stabilize your spine internally."
D)"This is the first of a series of surgeries you will require."

Question 5

It is suspected that a patient admitted with spinal cord injury has severe cord injury.The nurse would prepare the patient for which diagnostic test to determine the extent of this edema?

A)Angiography
B)Somatosensory-evoked potentials
C)CT scan
D)MRI

Question 6

A patient comes into the emergency department after being injured in an automobile crash in which a semi-truck hit her car from behind.The nurse will assess this patient for findings associated with which type of injury?

A)Ankylosing spondylitis
B)Axial loading
C)Hyperflexion
D)Hyperextension

Question 7

The nurse is caring for a patient with a fractured sacrum.The nurse would assess for which changes as a result of this fracture?

A)Altered sympathetic responses
B)Alteration in pain responses
C)Alteration in position sense
D)Altered parasympathetic responses

Question 8

A patient is admitted for a lumbar laminectomy.The nurse reinforces teaching that which portion of the vertebra will be removed?

A)Roof of the arch
B)Cartilage inside the vertebra
C)Pedicles that attach the arch to the body
D)Spinous process

Question 9

A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area.When assessing this patient,the nurse will expect to find sensory deficits beginning at and below which anatomical area?

A)Anterior thigh
B)Nipple line
C)Umbilicus
D)Groin

Question 10

A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension.Which finding would the nurse evaluate as indicating the therapy has had its desired effect?

A)Normal temperature
B)Systolic blood pressure of 85 mm Hg
C)Systolic blood pressure of 120 mm Hg
D)Mean arterial pressure of 88 Hg

Question 11

A patient is diagnosed with damage to the spinothalamic tract of the spinal cord.Which assessment finding would the nurse attribute to this damage?

A)The patient reports an unusual amount of pain.
B)Muscle spasms are occurring in the patient's right leg.
C)The patient has ataxia.
D)The patient is complaining of vertigo.

Question 12

A patient suffered an acute T6 spinal cord injury.Family has been told that the patient will likely be paraplegic.However,this morning the patient has limited use of her arms.How should the nurse explain this change?

A)"There must be a second area of fracture higher in the spine."
B)"The spinal cord is probably swollen above the area of original injury."
C)"These changes are due to the low blood pressure she had before she got to the hospital."
D)"This is a sign that she is dehydrated and will go away as we give her more IV fluids."

Question 13

A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS)was started intravenously.The patient has now been transferred to a neurointensive care unit in a large hospital.What interventions would the nurse in the receiving agency include in the plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Assess the patient's breath sounds every 2 hours.
B)Check all stools for blood.
C)Keep the patient on nothing by mouth (NPO)status.
D)Insert an indwelling urinary catheter so accurate intake and output (I&O)can be measured.
E)Monitor for the development of hypotension.

Question 14

A patient is diagnosed with a fracture of anterior and posterior columns of three cervical vertebrae.How would the nurse describe this injury?

A)As life threatening
B)As stable
C)As minor
D)As unstable

Question 15

A patient was admitted this morning after sustaining an acute spinal cord injury.This afternoon his neurological assessment shows some deterioration of function.How would the nurse explain this to the patient's family?

A)"Injured cells release potassium that causes destruction of the covering of nerves in the area injured."
B)"Decreased blood flow increases the size of the affected area."
C)"The body's inflammatory response has caused blood vessels in the area to dilate."
D)"Injury to nerves impairs the body's healing responses."

Question 16

A patient is admitted with a possible 2nd cervical vertebra injury.The nurse prepares for which most likely method to manage the patient's respiratory system?

A)Incentive spirometer every hour while awake
B)Quad coughing
C)Humidified oxygen via face mask
D)Intubation and mechanical ventilation

Question 17

A patient is admitted with a fractured mandible and several fractured ribs.Which priority intervention would the nurse anticipate?

A)Providing pain medication
B)Determining lung function by chest x-ray
C)Maintaining spinal cord injury precautions
D)Stabilizing the rib fractures

Question 18

The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair.Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Apply a binder around the patient's abdomen.
B)Be certain the patient is wearing compression stockings.
C)Swing the patient's legs to the side of the bed in one swift,smooth movement.
D)Gradually raise the head of the bed.
E)Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.

Question 19

A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra.The nurse will expect to find which deep tendon reflexes affected by this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Select all that apply.

A)Supinator
B)Patellar
C)Triceps
D)Biceps
E)Achilles