Deck 24: Spinal Cord Injury

Question 1

Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection?

A) Manage a mechanical wheelchair with a joystick.
B) Manage a mechanical wheelchair with hand control.
C) Manage a specially equipped wheelchair.
D) Manage an ordinary wheelchair.

Answer 1

Manage an ordinary wheelchair.

Question 2

On admission to the emergency department, a patient with a C5 compression fracture can move only his head and has flaccid paralysis of all extremities.The distraught family asks if the paralysis is permanent.What is the best response by the nurse?

A) "Yes.In all likelihood, the paralysis is probably permanent."
B) "No.Significant recovery of function should occur in a few days."
C) "It is too early to tell.When the spinal shock subsides, we will know more."
D) "You should talk to your physician about things of that nature."

Answer 2

"It is too early to tell.When the spinal shock subsides, we will know more."

Question 3

What should be the immediate intervention when a nurse recognizes autonomic dysreflexia in the patient with an SCI?

A) Flex the patient's legs using the knee gatch of the bed.
B) Cool the patient with alcohol solution.
C) Raise the head of the bed to at least 45 degrees.
D) Administer oxygen per mask.

Answer 3

Raise the head of the bed to at least 45 degrees.

Question 4

Which technique of opening the airway in the newly admitted patient with an SCI is the most appropriate?

A) Chin lift
B) Head tilt
C) Jaw thrust
D) Neck flexion

Question 5

After spinal shock has been resolved, an indwelling catheter is removed.What way should the nurse expect this patient to empty the bladder?

A) Manual expression (Credé method)
B) Spontaneous reflexive action
C) Normal voluntary control
D) Self-catheterization

Question 6

What technique should the nurse implement to move the impaired legs of a patient with an SCI to avoid stimulation muscle spasm?

A) Firmly grasping the calf muscle and the thigh muscle
B) Manipulating the limb by supporting the knee and ankle joints
C) Holding the foot upright and slowly dragging the limb into position
D) Requesting assistance to support the calf and thigh

Question 7

A paraplegic patient excitedly reports seeing his foot move when he was being turned.How is this phenomenon best explained?

A) Reflexive movement
B) Return of motor function
C) Early symptom of autonomic dysreflexia
D) Result of hypertonicity of the muscle

Question 8

Which statement made by a male patient with an SCI could be assessed as a positive adaptation to sexual dysfunction?

A) "I know I will never have a sexual relationship again."
B) "I need some suggestions as to how to direct my sexual energy into gardening or painting.or just anything."
C) "Can you arrange an appointment with a sex counselor so I can begin to examine alternative methods of sexual activity?"
D) "I think that after a while I will be able to have sexual relationships just like I had before my accident."

Question 9

What is the major advantage of the halo device over the Gardner-Wells tongs?

A) Separates the cervical vertebrae
B) Allows the patient out of bed
C) Aligns the cervical spine
D) Relieves pain

Question 10

A patient is receiving methylprednisolone.What purpose should the nurse explain this drug has in treating a patient with an SCI?

A) Reduces spinal cord cellular damage
B) Counteracts spinal shock
C) Increases blood supply to the injured cord
D) Enhances sexual function

Question 11

A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra?

A) Last thoracic
B) Second lumbar
C) First sacral
D) Coccygeal

Question 12

Which assessment leads the emergency department nurse to suspect that a patient's spinal cord injury (SCI)is below C4?

A) Voluntary eye movement
B) Ability to blink the eyelids
C) Unlabored respiration
D) Ability to make a facial grimace

Question 13

Which intervention by a nurse is effective in the prevention of autonomic dysreflexia in the patient with an SCI?

A) Ensure patency of the urinary catheter.
B) Give warm baths to the patient to stimulate vasodilation.
C) Keep lighting at a minimum to reduce stimulation.
D) Offer the patient four or five small meals daily.

Question 14

The family members of a patient with an SCI, who is in the rehabilitation phase, want to take the patient outdoors for a visit.It is 90 $\degree$ F outside and very humid.What should the nurse suggest?

A) Do not go outside at all but remain in the hospital.
B) Take a spray bottle to spray water to cool the patient by evaporation.
C) Take a light sweater to insulate the patient.
D) Have the patient drink at least 32 oz of water during the outing.

Question 15

Brown-Séquard syndrome results in which neurologic deficit?

A) Bilateral loss of pain sensation below the level of injury
B) Bilateral loss of temperature and motor function below the level of injury
C) Motor and sensory loss in the upper extremities only
D) Ipsilateral loss of motor function and contralateral loss of pain sensation and temperature

Question 16

A nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier.What action should the nurse implement?

A) Continue to monitor.
B) Inform the charge nurse.
C) Perform intermittent catheterizations.
D) Turn the patient to the right side.

Question 17

A distressed family member asks about the purpose of the Gardner-Wells tongs.Which is the most helpful explanation by the nurse regarding the action of Gardner-Wells tongs?

A) Compress the cervical vertebrae.
B) Immobilize the head.
C) Allow the patient to be moved out of bed.
D) Align the cervical vertebrae.

Question 18

A patient with an SCI begins to have seizures, and the blood pressure (BP)rises rapidly to 210/160 mm Hg.Which is the third indicator of the syndrome of autonomic dysreflexia?

A) Profuse vomiting
B) Hives on face and neck
C) Excessive urine output
D) Bradycardia

Question 19

Which assessment would indicate the resolution of spinal shock?

A) Extension and rigidity in affected limbs
B) Spastic involuntary movements in affected limbs
C) Tingling and burning in affected limbs
D) Voluntary purposeful movements of affected limbs

Question 20

During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance of the nurse's hand.The patient is unable to perform this action.Where does this assessment confirm that cord damage has occurred?

A) C4 to C5
B) L2 to L4
C) L5
D) S1

Question 21

What should a nurse include in a patient's plan of care when considering interventions for the outcome of prevention of contractures in a patient with an SCI?

A) Apply cold wraps to the limbs twice a day.
B) Perform full ROM exercises every 2 hours.
C) Use significant tactile stimuli each shift.
D) Apply splints to the limbs.

Question 22

What has occurred in the past 10 years to enhance rehabilitation of individuals with SCIs? (Select all that apply.)

A) Technologically advanced assistive aids
B) Rehabilitation personnel
C) Development of trauma centers
D) Health insurance
E) Rapid transport of victims

Question 23

The family of a patient with an SCI is concerned with the lack of bowel function 2 days after the injury.What is the best response by the nurse?

A) "Because of his injury, he will always need to have enemas for bowel evacuation."
B) "Medical management is delaying bowel action because it places pressure on the injury."
C) "Bowel function should return in approximately 3 days after the accident."
D) "We'll just have to wait and see if bowel action returns this week."

Question 24

What should a nurse emphasize regarding the rehabilitation of the patient with an SCI?

A) Rehabilitation is usually achieved within a few months after stabilization.
B) Rehabilitation will return the patient with an SCI to the preaccident functional level.
C) Rehabilitation focuses on adjustments necessary to reenter society and the workplace.
D) Rehabilitation completely targets self-care.

Question 25

A nurse is caring for a despondent young female patient with an SCI at C5.The patient verbalizes concern regarding sexual dysfunction.What should the nurse assure this patient she can still experience? (Select all that apply.)

A) Vaginal sensation
B) Vaginal orgasm
C) Normal menses
D) Intercourse
E) Children

Question 26

What changes occur with the intervertebral disks in older adults that increase the risk of injury? (Select all that apply.)

A) Fill with calcium deposits
B) Are less shock absorbent
C) Are herniated
D) Enlarge and swell
E) Lose water

Question 27

A home health nurse encourages the family of a patient with an SCI to use the assisted cough technique.What does this technique require the caregiver to do?

A) Assist the patient to inhale a bronchodilator spray and then cough.
B) Forcefully press on patient's back below the rib cage while the patient is in the prone position.
C) Assist the patient to lean forward, breathe deep, and then cough.
D) Apply pressure to diaphragm as the patient coughs.
E) Slap the patient on upper back while the patient is in the prone position.