Deck 24: Caring for the Patient With Spinal Cord Injuries

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?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Wear a helmet while riding a bicycle or motorcycle.
B) Eat a well-balanced diet with sufficient calcium.
C) Wear sunglasses.
D) Do not dive into unfamiliar water.
E) Do not ride in a car with someone who has been drinking.

Answer 1

Wear a helmet while riding a bicycle or motorcycle.
Do not dive into unfamiliar water.
Do not ride in a car with someone who has been drinking.

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?

A) "Tissue repair does not begin for 72 hours."
B) "We have to wait until spinal shock resolves."
C) "Neurons need time to regenerate, so it is hard to predict how you will progress."
D) "The most serious changes after an injury take days to develop."

Answer 2

"We have to wait until spinal shock resolves."

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.

Answer 3

0.25

Question 4

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

A) This patient should not be turned.
B) Place pillows under the patient's side for support turning the turn.
C) Have the patient grasp the side rail to turn.
D) Logroll the patient.

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?

A) Tilt the child's head back to help maintain an airway.
B) Place the child on the side to prevent aspiration.
C) Immobilize the neck, securing the head.
D) Try to rouse the child by gently shaking the shoulders.

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?

A) Try to calm the patient and make the environment soothing.
B) Assess for a full bladder.
C) Notify the health care provider.
D) Prepare the patient for diagnostic radiography.

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?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) Presence of a pressure ulcer
B) Kinked urinary catheter tubing
C) Respiratory congestion
D) Diarrhea
E) Fecal impaction

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?

A) Paraplegia
B) Neurogenic shock
C) High cervical injury
D) Temporary hypovolemia

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.

Question 10

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

A) 18-year-old male with a prior arrest for driving while intoxicated (DWI)
B) 20-year-old female with a history of substance abuse
C) 50-year-old female with osteoporosis
D) 35-year-old male who coaches a soccer team

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?

A) Increased episodes of hypoglycemia
B) Possible episodes of hyperglycemia
C) No change in the patient's glycemic parameters
D) Both hyper- and hypoglycemic episodes

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?

A) Remind the patient of her injury and try to comfort her.
B) Call the health care provider and get an order for radiologic evaluation.
C) Prepare the patient for surgery, as her condition is worsening.
D) Explain to the patient that this could be a common, temporary problem.

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?

A) "I will have less pain if I use the halo device."
B) "The halo device will allow me to get out of bed."
C) "I am less likely to get an infection with the halo device."
D) "The halo device does not have to stay in place as long."

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.
Standard Text: Click and drag the options below to move them up or down.

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.

Question 15

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

A) "The most common cause of spinal cord injury in your age group is trauma from motor vehicle accidents or sports-related accidents."
B) "Spinal tumors are the most common cause of all injuries to the spinal cord and are not dependent on age."
C) "Young people have a poorer survival rate than do older people."
D) "Nontraumatic causes of spinal cord injury such as infection or inflammation are more common in younger people."

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?

A) Hypoxia
B) Bradycardia
C) Elevated blood pressure
D) Tachycardia

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?.Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A) This patient has experienced an incomplete spinal injury.
B) The patient is likely to regain only limited motor control.
C) All deep tendon reflexes are affected.
D) The injury was likely a result of trauma to the C₁ to C₄ level of the spinal cord.
E) Tetraplegia is the term for the patient's neurological deficiencies.

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?

A) Hemiplegia
B) Paresthesia
C) Paraplegia
D) Tetraplegia

Question 19

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

A) Fluid Volume Deficit
B) Impaired Physical Mobility
C) Ineffective Breathing Pattern
D) Altered Tissue Perfusion

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?

A) Autonomic dysreflexia
B) Autonomic crisis
C) Autonomic shutdown
D) Autonomic failure

Question 21

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?

A) Insertion of a nasogastric tube
B) Regular assessment of the patient's bowel sounds
C) Administration of a lansoprazole (Prevacid)
D) Elevating the end of the bed to 35 degrees

Question 22

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. Select all that apply.

A) It is likely a result of a hyperextension injury to the cervical spine.
B) Function, if restored, will occur first in the hands.
C) Loss of function will be greatest in the lower extremities.
D) Prognosis for recovery is poor.
E) The patient may have preexisting degenerative bone changes.

Question 23

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. Select all that apply.

A) Adapting to the realization of the patient's limitations
B) Providing the emotional support required for this adjustment
C) Reaching the patient's highest potential for independence
D) Managing the physical pain such injuries cause
E) Assimilating back into the patient's home environment

Question 24

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?

A) Bladder function only
B) Bowel function only
C) Intact bladder and bowel function
D) Loss of both bladder and bowel function

Question 25

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?

A) Spinal shock usually results in temporary paralysis.
B) There will likely be some minor improvement in the degree of paralysis.
C) Spinal shock is irreversible and the paralysis is likely to be permanent.
D) The severity of the injuries cannot be determined until the spinal shock resolves.

Question 26

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. Select all that apply.

A) Check each stool for occult blood.
B) Administer stool softener as prescribed.
C) Institute chemical stimulation to initiate bowel evacuation.
D) Place the patient in an adult incontinence garment.
E) Manage parenteral feedings as ordered.

Question 27

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. Select all that apply.

A) Fit the patient for an abdominal binder and thigh-length compression stockings.
B) Monitor administration of atropine and other vasoactive agents as ordered or by protocol.
C) Administer anticoagulant medication as ordered.
D) Measure and record the diameter of the calf every shift.
E) Measure and record intake and output.

Question 28

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. Select all that apply.

A) Sensory perception
B) Body image
C) Cognitive abilities
D) Role performance
E) Independence

Question 29

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?

A) "We will begin bowel and bladder training in 2 weeks."
B) "You will experience some role changes in your relationship."
C) "The vocational rehabilitation company will contact you next week to set up your schedule."
D) "You should plan respite time away from your husband every week."

Question 30

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?

A) "It may be a few weeks before he is strong enough to breathe on his own."
B) "We don't know if he will be able to talk when we get him off the ventilator."
C) "There are ways we can teach both of you to communicate that will not require his being off the ventilator."
D) "We need to focus on his getting better, not on how he will communicate."

Question 31

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?

A) The nurse asks the patient to identify members of his support system.
B) The patient says, "I would enjoy some fast food for lunch."
C) The nurse enters the room and finds the patient crying.
D) The patient tells the nurse he was once treated for depression.

Question 32

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

A) Only a mild motor deficiency
B) Restoration of sensory function first
C) Some neurotransmission of impulses
D) A good prognosis for recovery

Question 33

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. Select all that apply.

A) Monitoring skin temperature in lower extremities
B) Assessing for abdominal distention
C) Bladder scan postvoiding
D) Assessing pulse oximetry levels with vital signs
E) Strict output monitoring

Question 34

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?

A) "You should consider adoption if you want to have a family."
B) "Sexual intercourse will not be pleasurable for you any longer."
C) "Your rehabilitation specialist will talk to you about this concern."
D) "It is possible for some women with spinal cord injuries to become pregnant and bear children."

Question 35

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?

A) As soon as the patient arrives in the emergency department
B) As soon as assessment is completed and a treatment plan is established
C) As soon as a cross-table lateral cervical spine X-ray is taken
D) As soon as the patient is admitted to the neurological intensive care unit