Question 1

The school nurse is teaching a session on ways to prevent spinal cord injuries to a group of middle-school students. Which health promotion information should the nurse include?. Select all that apply.

Accepted Answer

Wearing a helmet (A) protects the head and neck during falls or accidents. Avoiding diving into unfamiliar water (D) prevents head and neck injuries from hitting the bottom. Not riding with someone who has been drinking (E) reduces the risk of car accidents, which can cause spinal injuries.

Question 2

How should the nurse explain to a patient with a spinal cord injury why the extent of injury cannot be determined for several days to a week?

Accepted Answer

Spinal shock is a temporary period of diminished reflexes that occurs following a spinal cord injury. It can last for several hours to weeks, during which time it is difficult to determine the extent of the injury. Waiting for spinal shock to resolve allows for a more accurate assessment of the patient's neurological function.

Question 3

The health care provider orders
2.5 mg IV of morphine sulfate (Morphine) to be administered to a patient with a ruptured intervertebral disc. The nurse has a 1 milliliter (mL) vial containing 10 mg of morphine sulfate. The nurse needs to withdraw ______ mL of morphine sulfate from the vial.

Accepted Answer

0.25

Question 4

Which nursing action is appropriate for turning a patient who sustained a spinal cord injury?

Accepted Answer

Logrolling is the appropriate technique for turning a patient who has sustained a spinal cord injury to prevent any further damage to the spinal cord. It involves the use of a team of healthcare professionals to carefully turn the patient onto their side while maintaining the alignment of their head, neck, and spine. This technique is important to prevent pressure areas and shearing forces on the spinal cord during the turning process. The other options are not appropriate for a patient with a spinal cord injury as they can result in further injury.

Question 5

The school nurse is called after a student falls down a flight of stairs. The student is breathing but unconscious. After calling the ambulance, which is the most appropriate action by the nurse?

Accepted Answer

Immobilizing the neck and securing the head is the most appropriate action to prevent further injury to the cervical spine. Tilt the head back may cause injury to the cervical spine if there is a fracture. Placing the child on the side is not recommended because it may not adequately protect the spine. Trying to rouse the child by shaking the shoulders is not recommended because it can cause further injury if there is a cervical spine injury.

Question 6

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?

Accepted Answer

A severe headache and an anxious feeling in a patient with a spinal cord injury at the T1 level could be symptoms of autonomic dysreflexia, a condition that can occur in individuals with spinal cord injuries above T6. Autonomic dysreflexia is often triggered by a noxious stimulus below the level of injury, with a full bladder being a common cause. Assessing for a full bladder is an appropriate initial reaction to address and potentially remove the triggering stimulus.

Question 7

A patient with a T5 spinal cord injury has manifestations of autonomic dysreflexia. Which assessments would indicate a possible cause for this condition?. Select all that apply.

Accepted Answer

Autonomic dysreflexia is a potentially life-threatening complication that can occur in patients with spinal cord injuries at T6 level or above. The condition is characterized by a sudden onset of hypertension, headache, flushing, and diaphoresis. It can be caused by any noxious stimuli below the level of injury, such as a full bladder, urinary tract infection, fecal impaction, pressure ulcers, etc. Therefore, assessments such as checking for the presence of pressure ulcers, kinked urinary catheter tubing, or fecal impaction are essential in identifying the possible cause and providing prompt intervention to prevent further complications. Respiratory congestion or diarrhea may not be directly related to autonomic dysreflexia.

Question 8

The patient is admitted with injuries that were sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right side, absent bowel sounds, zero urine output, and palpation of a distended bladder. These signs are most consistent with which condition?

Accepted Answer

The patient's low blood pressure, flaccid paralysis, absent bowel sounds, zero urine output, and distended bladder suggest neurogenic shock. This type of shock occurs as a result of damage to the spinal cord, which disrupts the sympathetic nervous system's ability to maintain vascular tone and regulate heart rate. This leads to hypotension, bradycardia, and loss of autonomic control over bladder and bowel function. Paraplegia (A) refers to paralysis of both lower extremities, while high cervical injury (C) would result in tetraplegia (paralysis of all four extremities) and respiratory compromise. Temporary hypovolemia (D) may be a contributing factor but does not account for all of these findings.

Question 9

The health care provider orders 15 mg IV of ketorolac (Toradol) for a patient who has recently undergone a spinal fusion. The nurse has a 5 milliliter (mL) ampule containing 60 mg of ketorolac. The nurse withdraws ______ mL of ketorolac from the ampule.

Accepted Answer

The answer of The health care provider orders 15 mg...

Question 10

Which patient is at highest risk for a spinal cord injury?

Accepted Answer

The patient who is most at risk for a spinal cord injury is the 18-year-old male with a prior arrest for driving while intoxicated (DWI). This is because driving under the influence greatly increases the chances of a motor vehicle accident, which is a common cause of spinal cord injury. The other patients listed do not have as clear of a risk factor for spinal cord injury.

Question 11

A patient with a spinal cord injury was given IV Decadron (dexamethasone) after arriving in the emergency department. The patient also has a history of hypoglycemia. During the hospital stay, the nurse would expect to see which response to this medication?

Accepted Answer

Dexamethasone is a steroid medication that can cause hyperglycemia (elevated blood sugar levels) in some patients. Patients with a history of hypoglycemia may be at increased risk for this side effect. Therefore, the nurse should monitor the patient's blood glucose levels closely and be prepared to manage any episodes of hyperglycemia that may occur.

Question 12

A hospitalized patient with a C7 cord injury asks, "Why can't I feel my legs anymore?" Which is the most appropriate action by the nurse?

Accepted Answer

The nurse should explain to the patient that the lack of sensation is a common consequence of a spinal cord injury, and that it may be temporary or permanent. It is important to provide education and support to the patient to promote understanding and coping with the injury. Calling the health care provider or preparing the patient for surgery are not appropriate actions based on the information given in the question.

Question 13

The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?

Accepted Answer

The benefit of using a halo fixation device instead of Gardner-Wells tongs is that the halo device allows the patient to get out of bed and move around, while Gardner-Wells tongs require the patient to remain in bed. The other options do not differentiate between the two devices.

Question 14

The nurse witnesses a motor vehicle accident (MVA) while off duty. Upon approaching the scene, the nurse observes a victim lying on the ground after being ejected from the vehicle. Beginning with the action the nurse must first take, place the actions in the correct order. All options must be used.
A) Check the victim's breathing.
B) Check the victim's pulse.
C) Check the victim's airway.
D) Immobilize the victim's spine.
E) Check for responsiveness.

Accepted Answer

The answer of The nurse witnesses a motor vehicle accident...

Question 15

The nurse is providing community education regarding spinal cord injuries to a group of young adults. Which information should the nurse include?

Accepted Answer

According to the National Spinal Cord Injury Statistical Center, the most common causes of spinal cord injury in young adults are trauma from car accidents, falls, sports-related accidents, and violence.

Question 16

The nurse suspects that a patient with spinal cord injury (SCI) is experiencing autonomic dysreflexia. The nurse elevates the head of the bed and removes the patient's compression stockings while searching for the cause of this response. Performing these interventions helps to avoid which very dangerous complication of autonomic dysreflexia?

Accepted Answer

Autonomic dysreflexia is characterized by sudden and severe hypertension that can lead to stroke, hemorrhage or cardiac dysrhythmias. Elevating the head of the bed and removing any constrictive clothing or equipment can decrease the blood pressure and prevent these complications. Hypoxia, bradycardia, and tachycardia can occur as a result of autonomic dysreflexia, but they are not as dangerous as the sudden elevation in blood pressure.

Question 17

The nursing assessment confirms that the patient has experienced loss of voluntary motor and sensory function of both upper and lower extremities, as well as bowel and bladder control, due to a spinal cord injury (SCI). The nurse recognizes that which is true regarding this patient?. Select all that apply.

Accepted Answer

The answer of The nursing assessment confirms that the patient...

Question 18

A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and the lower part of the body. The nurse should use which medical term to correctly describe this in documentation?

Accepted Answer

Tetraplegia (also known as quadriplegia) is the medical term used to describe complete paralysis of both the upper and lower extremities, while paraplegia only involves paralysis of the lower extremities. Hemiplegia refers to paralysis of one side of the body, and paresthesia refers to abnormal sensations such as tingling or numbness.

Question 19

The nurse would prioritize which nursing diagnosis when caring for a patient diagnosed with a spinal cord injury?

Accepted Answer

A spinal cord injury can affect the respiratory muscles, leading to an ineffective breathing pattern, which is a critical and immediate concern.

Question 20

A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the patient should not develop a full bladder because what emergency condition can occur if it is not corrected quickly?

Accepted Answer

Autonomic dysreflexia is a potentially life-threatening emergency condition that can occur in patients with spinal cord injuries who have a full bladder, among other triggers. It is important to prevent or promptly treat a full bladder in these patients to avoid the development of autonomic dysreflexia. Choice B, C, and D are not correct because these conditions are not commonly associated with spinal shock or bladder distension.

Quiz 24: Caring for the Patient With Spinal Cord Injuries