Deck 29: Spinal Cord Injury

Question 1

To avoid stimulating a muscle spasm,the nurse will move the impaired legs of a patient with a SCI by:

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.

Answer 1

Manipulating the limb by supporting the knee and ankle joints.

Question 2

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 2

Manage an ordinary wheelchair

Question 3

The family members of a patient with a SCI,who is in the rehabilitation phase,want to take the patient outdoors for a visit.Because it is 90° outside and very humid,the nurse will suggest that they:

A) Do not go outside at all buy 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 ounces of water during the outing.

Answer 3

Take a spray bottle to spray water to cool the patient by evaporation.

Question 4

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

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

Question 5

The 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 6

When asked why the patient is receiving the methylprednisolone,the nurse explains that the drug is used in the patient with a SCI to:

A) Reduce spinal cord cellular damage.
B) Counteract spinal shock.
C) Increase blood supply to the injured cord.
D) Enhance sexual function.

Question 7

A distressed family member asks about the purpose of the Gardner-Wells tongs.The most helpful explanation by the nurse would be that the 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 8

During a neurologic assessment,the nurse asks the patient to dorsiflex the foot against the resistance of the nurse's hand.The inability to perform this action confirms that cord damage has occurred at:

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

Question 9

Which intervention by the nurse would be effective in the prevention of autonomic dysreflexia in the patient with a 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 10

After spinal shock has been resolved,the indwelling catheter is removed.The nurse tells the patient to expect the bladder to empty by:

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

Question 11

The nurse explains that the major advantage of the halo device over the Gardner-Wells tongs is that the halo device:

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

Question 12

On admission to the emergency department,the 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.The nurse's best response would be:

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."

Question 13

When the nurse recognizes autonomic dysreflexia in the patient with a SCI,the immediate intervention should be to:

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.

Question 14

A paraplegic patient excitedly reports seeing his foot move when he was being turned.This phenomenon is best explained as a(n):

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

Question 15

The nurse explains to the family of a patient with quadriplegia that intravenous (IV)drugs are the most effective method of administration,because drugs injected intramuscularly (IM)are:

A) Too concentrated
B) Too irritating to poorly perfused tissue
C) Not absorbed well below the level of the injury
D) Too small a dose to be effective

Question 16

When recording the findings of muscle strength,the nurse records a "2" for the right arm.This means that the muscles of the arm show:

A) Weak contraction
B) Muscle movement when supported
C) Active muscle movement without support
D) Full, active range-of-motion (ROM) exercises against resistance

Question 17

The assessment that ensures the emergency department nurse that a patient's spinal cord injury (SCI)is below C4 is:

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

Question 18

The 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 19

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

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

Question 20

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 21

The nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2 hours earlier.The nurse should:

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

Question 22

The nurse considering interventions for the outcome of prevention of contractures in a patient with a SCI will include which one of the following in the nursing care plan?

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 23

Before taking a magnetic resonance image (MRI),the patient asks why metal objects and the MRI machine are such concerns.The nurse's best explanation is that the MRI machine will:

A) Cause metal objects to spark, similar to a microwave
B) Deactivate the battery in a pacemaker
C) Cause metal to heat up and burn the patient
D) Not transmit clear data if metal is present
E) Attract any metal into the MRI chamber

Question 24

The nurse assures a despondent young female patient with a SCI who is at risk for sexual dysfunction that although her lesion is at C5,she can still have:

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

Question 25

The family of a patient with a SCI is concerned with the lack of bowel function 2 days after the injury.The nurse's best response would be:

A) "Due to 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 26

The nurse cautions an 85-year-old golfer that he should take care to protect his back during his backswing because the intervertebral disks in older adults undergo changes to the point that they:

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

Question 27

The home health nurse encourages the family of a patient with a SCI to use the assisted cough technique,which requires the caregiver to:

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.

Question 28

Which statement made by a male patient with a SCI could be assessed as a positive adaptation to the nursing diagnosis of "Sexual dysfunction,related to altered body function?"

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 29

The family of a patient with an SCI at C4 asks whether the patient will ever be free of the ventilator.The nurse's best response is:

A) "Yes. Rehabilitation is very difficult, but ventilator-free life can be accomplished."
B) "No. A ventilator is essential to him."
C) "Yes. Special oxygen masks will allow him to have time off the ventilator."
D) "Yes. A small portable ventilator can be attached to the wheelchair."

Question 30

The nurse should emphasize that the rehabilitation of the patient with a SCI:

A) Is usually achieved within a few months after stabilization.
B) Will return the patient with a SCI to the preaccident functional level.
C) Focuses on adjustments necessary to reenter society and the workplace.
D) Completely targets self-care.

Question 31

The nurse reminds the patient that successful rehabilitation of individuals with SCIs has been enhanced over the last 10 years by the advent of new:

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

Question 32

The nurse refers to the ___________ __________ to assess the extent of sensory loss and specific nerve root enervation.

Question 33

When the patient with a SCI inquires what the physician means by a cone-down,the nurse explains that:

A) A cone is surgically placed over the spine to protect the cord.
B) Marks will be placed on either side of the injury to mark the area.
C) A cone-shaped wedge of bone will be placed between the vertebrae.
D) A detailed x-ray image will be taken of the spinal injury.

Question 34

After a computed tomographic (CT)scan,the nurse will encourage the patient with a SCI to:

A) Sit up at a 30-degree angle.
B) Prevent chilling.
C) Drink plenty of water.
D) Avoid bearing down.