Question 1

The nurse is caring for a patient who has been diagnosed with an incomplete spinal cord injury SCI) that has resulted in central cord syndrome. The nurse expects which findings related to this injury? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse is caring for a patient...

Question 2

A patient sustained a C4 fracture in a diving accident. The patient's wife says, "I'll be so glad when he gets off the ventilator so that he can communicate with me." How should the nurse respond to this statement?

Accepted Answer

Option C offers a positive response that provides the wife with hope for the future, as well as a practical solution to the current situation. Options A and D either don't directly address the wife's concern or fail to offer any constructive advice. Option B could cause undue anxiety or negativity.

Question 3

A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the paralysis is likely to last, the nurse's response is based on which understanding?

Accepted Answer

The answer of A patient is admitted after a fall...

Question 4

A patient with a spinal cord injury SCI) has a nursing diagnosis of Risk for Ineffective Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which intervention in the patient's plan of care? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient with a spinal cord injury...

Question 5

The nurse is preparing to discuss discharge planning with a patient who is hemiplegic as a result of a diving accident and with the patient's wife, who will be his primary caregiver. Which statement by the nurse would specifically address the needs of the caregiving wife?

Accepted Answer

Option D specifically addresses the needs of the caregiving wife by suggesting that she plan respite time away from her husband every week. This will help prevent caregiver burnout and provide an opportunity for her to recharge and take care of her own needs. Option A addresses the patient's needs but not the caregiver's needs. Option B is too vague and does not provide actionable information. Option C may be important for the patient's long-term recovery, but it does not address the immediate needs of the caregiver.

Question 6

The nurse is assessing the psychosocial status of a patient who experienced a spinal cord injury. What would provide the best subjective evidence of the patient's state of mind?

Accepted Answer

The answer of The nurse is assessing the psychosocial status...

Question 7

A patient was admitted after falling from the roof of a one-story building. Assessment reveals presence of a patellar reflex, but loss of sensation in part of both feet. The nurse would plan for which level of bowel and bladder function?

Accepted Answer

Loss of sensation in both feet indicates potential spinal cord damage, specifically affecting the sacral segments. This suggests loss of both bladder and bowel function, requiring interventions such as catheterization and bowel management.

Question 8

The nurse recognizes that the rehabilitation goal for a patient who has experienced a spinal cord injury SCI) is to assist the patient in which activities? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse recognizes that the rehabilitation goal...

Question 9

The nurse has assessed a patient who was admitted for rehabilitation after a fall that resulted in hemiplegia. The patient's care plan may require nursing diagnoses related to which concerns? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of The nurse has assessed a patient who...

Question 10

A patient who has experienced an incomplete spinal cord injury SCI) is most likely to experience which effects?

Accepted Answer

In an incomplete SCI, there is some degree of intact neural transmission and not complete damage to the spinal cord. Therefore, the patient may experience some neurotransmission of impulses. A and B are incorrect as incomplete SCI can also result in moderate to severe motor and sensory deficits. D is incorrect as the prognosis for recovery depends on the severity and location of the injury, not just whether it is incomplete or complete.

Question 11

Risk for Constipation related to impaired gastric motility is added to the nursing care plan of a patient with a new spinal cord injury SCI). The nurse would plan which interventions to address this diagnosis? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

A) Checking each stool for occult blood is not necessary for addressing constipation related to impaired gastric motility.
B) Administering stool softeners as prescribed can help prevent constipation and promote bowel evacuation.
C) Instituting chemical stimulation, such as the use of suppositories or enemas, can also help initiate bowel evacuation.
D) Placing the patient in an adult incontinence garment is not an appropriate intervention for constipation related to impaired gastric motility.
E) Managing parenteral feedings as ordered can help prevent constipation and maintain bowel function in patients with impaired gastric motility.

Question 12

A female patient who sustained a spinal cord injury resulting in paraplegia asks the nurse if she will ever be able to have children. How should the nurse respond?

Accepted Answer

It is important for the nurse to provide accurate and current information to the patient. Women with spinal cord injuries can become pregnant and bear children, although they may face challenges and require specialized medical care during pregnancy and childbirth. The nurse should refer the patient to a reproductive specialist or discuss options for assistive reproductive technologies if desired. It is not appropriate to suggest adoption or make assumptions about the patient's sexual function. Referring the patient to a rehabilitation specialist may be helpful but does not directly address the patient's concern about fertility.

Question 13

A patient with an incomplete spinal cord injury is being transferred from intensive care to the neurological trauma unit. The nurse realizes that in order to minimize the patient's risk of developing autonomic hyperreflexia, which interventions should be included in the patient's care plan? Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.

Accepted Answer

The answer of A patient with an incomplete spinal cord...

Question 14

Prehospital emergency personnel have placed a patient in a head brace and on a backboard after a motor vehicle accident. The nurse would advocate for the patient to be removed from this immobilization at what time?

Accepted Answer

The patient should be removed from the immobilization as soon as assessment is completed and a treatment plan is established. Prolonged immobilization can cause complications such as pressure ulcers, respiratory compromise, and psychological distress. However, the healthcare provider should ensure that it is safe to remove the immobilization and the patient's spine is cleared before doing so.

Question 15

A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing intervention is primarily directed at minimizing this risk?

Accepted Answer

The answer of A patient with a recent spinal cord...

Quiz 24: Caring for the Patient With Spinal Cord Injuries