Spinal injury and ICP Nclex Questions
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1. 1. In which order will the nurse perform the
following actions when caring for a patient
with possible cervical spinal cord trauma who is
admitted to the emergency department?
a. Administer O2 using a non-rebreathing
mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient's head, neck, and
spine.
d. Transfer the patient to radiology for spinal
CT.
2. 5. The nurse is working on a surgical floor. The
nurse must logroll a male client following a:
a. laminectomy.
b. thoracotomy.
c. hemorrhoidectomy.
d. cystectomy.
3. 10. For a male client with suspected increased
intracranial pressure (ICP), a most appropriate
respiratory goal is to:
a. prevent respiratory alkalosis.
b. lower arterial pH.
c. promote carbon dioxide elimination.
d. maintain partial pressure of arterial oxygen
(PaO2) above 80 mm Hg
4. 13. A patient with a neck fracture at the C5
level is admitted to the intensive care unit
(ICU) following initial treatment in the
emergency room. During initial assessment of
the patient, the nurse recognizes the presence
of spinal shock on finding
a. hypotension, bradycardia, and warm
extremities.
b. involuntary, spastic movements of the arms
and legs.
c. the presence of hyperactive reflex activity
below the level of the injury.
d. flaccid paralysis and lack of sensation below
the level of the injury.
Correct Answer: C, A, B, D
Rationale: The first action should be to prevent further injury by stabilizing the
patient's spinal cord. Maintenance of oxygenation by administration of 100% O2 is
the second priority. Because neurogenic shock is a possible complication,
continuous monitoring of heart rhythm and BP is indicated. CT scan to determine
the extent and level of injury is needed once initial assessment and stabilization is
accomplished.
Cognitive Level: Application Text Reference: p. 1596
Nursing Process: Implementation NCLEX: Physiological Integrity
5. Answer A. The client who has had spinal surgery, such as laminectomy, must be
logrolled to keep the spinal column straight when turning. The client who has had
a thoracotomy or cystectomy may turn himself or may be assisted into a
comfortable position. Under normal circumstances, hemorrhoidectomy is an
outpatient procedure, and the client may resume normal activities immediately
after surgery.
0. Answer C. The goal of treatment is to prevent acidemia by eliminating carbon
dioxide. That is because an acid environment in the brain causes cerebral vessels
to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering
arterial pH may bring about acidosis, an undesirable condition in this case. It isn't
necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately
oxygenate most clients.
Correct Answer: D
Rationale: Clinical manifestations of spinal shock include decreased reflexes, loss
of sensation, and flaccid paralysis below the area of injury. Hypotension,
bradycardia, and warm extremities are evidence of neurogenic shock. Involuntary
spastic movements and hyperactive reflexes are not seen in the patient at this
stage of spinal cord injury.
Cognitive Level: Comprehension Text Reference: p. 1590
Nursing Process: Assessment NCLEX: Physiological Integrity
5. 14. When caring for a patient Correct Answer: B
who had a C8 spinal cord injury Rationale: The nurse has identified that the cough effort is poor, so the initial action should be to
10 days ago and has a weak use assisted coughing techniques to improve the ability to mobilize secretions. Administration of
cough effort, bibasilar crackles, oxygen will improve oxygenation, but the data do not indicate hypoxemia, and oxygen will not
and decreased breath sounds, help expel respiratory secretions. The use of the spirometer may improve respiratory status, but
the initial intervention by the the patient's ability to take deep breaths is limited by the loss of intercostal muscle function.
nurse should be to Suctioning may be needed if the patient is unable to expel secretions by coughing but should not
a. administer oxygen at 7 to 9 be the nurse's first action.
L/min with a face mask.
b. place the hands on the Cognitive Level: Application Text Reference: p. 1602
epigastric area and push upward Nursing Process: Implementation NCLEX: Physiological Integrity
when the patient coughs.
c. encourage the patient to use
an incentive spirometer every 2
hours during the day.
d. suction the patient's oral and
pharyngeal airway.
6. 15. The nurse is positioning the 15. Answer B. The head of the client with increased intracranial pressure should be positioned so
female client with increased the head is in a neutral midline position. The nurse should avoid flexing or extending the client's
intracranial pressure. Which of neck or turning the head side to side. The head of the bed should be raised to 30 to 45 degrees.
the following positions would Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure
the nurse avoid? down.
a. Head mildline
b. Head turned to the side
c. Neck in neutral position
d. Head of bed elevated 30 to
45 degrees
7. 16. A female client has clear 16. Answer D. Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar
fluid leaking from the nose skull fracture. CSF can be distinguished from other body fluids because the drainage will separate
following a basilar skull fracture. into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also
The nurse assesses that this is tests positive for glucose.
cerebrospinal fluid if the fluid:
a. Is clear and tests negative for
glucose
b. Is grossly bloody in
appearance and has a pH of 6
c. Clumps together on the
dressing and has a pH of 7
d. Separates into concentric
rings and test positive of
glucose
8. 16. A patient with a T1 spinal Correct Answer: B
cord injury is admitted to the Rationale: The patient with a T1 injury can expect to retain full motor and sensory function of the
intensive care unit (ICU). The arms. Use of only the shoulders is associated with cervical spine injury. Total loss of respiratory
nurse will teach the patient and function occurs with injuries above the C4 level and is permanent. Bradycardia is associated with
family that injuries above the T6 level.
a. use of the shoulders will be
preserved. Cognitive Level: Application Text Reference: p. 1594
b. full function of the patient's Nursing Process: Implementation NCLEX: Physiological Integrity
arms will be retained.
c. total loss of respiratory
function may occur temporarily.
d. elevations in heart rate are
common with this type of injury.
9. 17. A male client with a spinal cord 17. Answer D. The most frequent cause of autonomic dysreflexia is a distended bladder.
injury is prone to experiencing Straight catheterization should be done every 4 to 6 hours, and foley catheters should be
automatic dysreflexia. The nurse checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other
would avoid which of the following causes, so maintaining bowel regularity is important. Other causes include stimulation of the
measures to minimize the risk of skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in
recurrence? these areas.
a. Strict adherence to a bowel
retraining program
b. Keeping the linen wrinkle-free
under the client
c. Preventing unnecessary pressure
on the lower limbs
d. Limiting bladder catheterization
to once every 12 hours
10. 18. A patient with a paraplegia Correct Answer: A
resulting from a T10 spinal cord Rationale: Because the patient's bladder is spastic and will empty in response to
injury has a neurogenic reflex overstretching of the bladder wall, the most appropriate method is to avoid incontinence by
bladder. When the nurse develops a emptying the bladder at regular intervals through intermittent catheterization. Assisting the
plan of care for this problem, which patient to the toilet will not be helpful because the bladder will not empty. The Credé
nursing action will be most method is more appropriate for a bladder that is flaccid, such as occurs with a reflexic
appropriate? neurogenic bladder. Catheterization after voiding will not resolve the patient's incontinence.
a. Teaching the patient how to self-
catheterize Cognitive Level: Application Text Reference: p. 1605
b. Assisting the patient to the toilet Nursing Process: Planning NCLEX: Physiological Integrity
q2-3hr
c. Use of the Credé method to
empty the bladder
d. Catheterization for residual urine
after voiding
11. 20. The nurse discusses long-range Correct Answer: D
goals with a patient with a C6 spinal Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on
cord injury. An appropriate patient flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not
outcome is be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn
a. transfers independently to a independently in bed.
wheelchair.
b. drives a car with powered hand Cognitive Level: Application Text Reference: p. 1594
controls. Nursing Process: Planning NCLEX: Physiological Integrity
c. turns and repositions self
independently when in bed.
d. pushes a manual wheelchair on
flat, smooth surfaces.
12. 22. A 26-year-old patient with a C8 Correct Answer: D
spinal cord injury tells the nurse, "My Rationale: Maintenance of sexuality is an important aspect of rehabilitation after spinal
wife and I have always had a very cord injury and should be handled by someone with expertise in sexual counseling.
active sex life, and I am worried that Although the patient should discuss these issues with his wife, open communication about
she may leave me if I cannot function this issue may be difficult without the assistance of a counselor. Sildenafil does assist with
sexually." The most appropriate erectile dysfunction after spinal cord injury, but the patient's sexuality is not determined
response by the nurse to the patient's solely by the ability to have an erection. Reflex erections are common after upper motor
comment is to neuron injury, but these erections are uncontrolled and cannot be maintained during coitus.
a. advise the patient to talk to his wife
to determine how she feels about his Cognitive Level: Application Text Reference: p. 1608
sexual function. Nursing Process: Implementation NCLEX: Psychosocial Integrity
b. tell the patient that sildenafil
(Viagra) helps to decrease erectile
dysfunction in patients with spinal cord
injury.
c. inform the patient that most patients
with upper motor neuron injuries have
reflex erections.
d. suggest that the patient and his wife
work with a nurse specially trained in
sexual counseling.
13. 27. When caring for a patient who was Correct Answer: C
admitted 24 hours previously with a C5 Rationale: Edema around the area of injury may lead to damage above the C4 level, so
spinal cord injury, which nursing action the highest priority is assessment of the patient's respiratory function. The other actions are
has the highest priority? also appropriate but are not as important as assessment of respiratory effort.
a. Continuous cardiac monitoring for
bradycardia Cognitive Level: Application Text Reference: p. 1602
b. Administration of Nursing Process: Assessment NCLEX: Physiological Integrity
methylprednisolone (Solu-Medrol)
infusion
c. Assessment of respiratory rate and
depth
d. Application of pneumatic
compression devices to both legs
14. A client recovering from a head injury D. exhaling during repositioning
is arousable and participating in care. (activities that increase intra-throacic and intra-abdominal pressures cause indirect
The nurse determines that the client elevation of the ICP. Exhaling during activities such as repositioning or pulling up in bed
understands measures to prevent opens the glottis, which prevents intra-thoracic pressure from rising).
elevations in intracranial pressure if
the nurse observes the client doing
which of the following activities?
A. blowing the nose
B. isometric exercises
C. coughing vigorously
D. exhaling during repositioning
15. A client with a spinal cord injury is 4. limiting bladder cath to once q12h
prone to experiencing autonomic (the most frequent cause of autonomic dysreflexia is a distended bladder . Straight cath
dysreflexia. The nurse should avoid should be performed q4-6 hrs and foley cath should be checked frequently for kinks in tubing
which measure to minimize the risk . Constipation and fecal impaction are other causes, so maintaining bowel irregularity is
of recurrence? important .
1. strict adherence to a bowel
retraining program
2. keeping the linen wrinkle free
under the client
3. avoiding unnecessary pressure
on the lower limbs
4. limiting bladder catheterization
to once every 12 hours
16. During assessment of a patient with C. assess lungs sounds and respiratory rate and depth
a spinal cord injury, the nurse Rationale: Because pneumonia and atelectasis are potential problems RT ineffective coughing
determines that the patient has a function, the nurse should assess the patient's breath sound and resp function to determine
poor cough with diaphragmatic whether secretions are being retained or whether there is progression of resp impairment.
breathing. Based on this finding, the Suctioning is not indicated unless lung sounds indicate retained secretions: position changes
nurses' first action should be to will help mobilize secretions. Intubation and mechanical ventilation are used if the patient
a. initiate frequent turning and becomes exhausted from labored breathing or if ABGs deteriorate.
repositioning
b. use tracheal suctioning to
remove secretions
c. assess lung sounds and
respiratory rate and depth
d. prepare the patient for
endotracheal intubation and
mechanical ventilation
17. During the patient's process of A. helps the patient understand that working through the grief will be a lifelong process
grieving for the losses resulting
from spinal cord injury, the nurse
a. helps the patient understand that
working through the grief will be a
lifelong process
b. should assist the patient to move
through all stages of the mourning
process to acceptance
c. lets the patient know that anger
directed at the staff or the family is
not a positive coping mechanism
d. facilitates the grieving process
so that it is completed by the time
the patient is discharged from
rehabilitation
18. Following a T2 spinal cord injury, D. nasogastric suctioning
the patient develops paralytic ileus. Rationale: During the first 2 to 3 days after a spinal cord injury, paralytic ileus may occur, and
While this condition is present, the NG suction must be used to remove secretions and gas from the GI tract until peristalsis
nurse anticipates that the patient resumes. IV fluids are used to maintain fluid balance but do not specifically relate to paralytic
will need ileus. Tube feedings would be used only for patients who had difficulty swallowing and not
a. IV fluids until peristalsis is returned; PN would be used only if the paralytic ileus was unusally
b. tube feedings prolonged.
c. parenteral nutrition
d. nasogastric suctioning
19. Goals of rehabilitation for the B, C, D, E
patient with an injury at the C6 level
include (select all that apply)
a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from
wheelchair
20. The healthcare provider has ordered C. BP of 106/82
IV dopamine (Intropin) for a patient Rationale: Dopamine is a vasopressor that is used to maintain BP during states of
in the emergency deparement with hypotension that occur during neurogenic shock associated with spinal cord injury. Atropine
a spinal cord injury. The nurse would be used to treat bradycardia. The T reflects some degree of poikilothermism, but this is
determines that the drug is having not treated with medications.
the desired effect when assessment
findings include
a. pulse rate of 68
b. respiratory rate of 24
c. BP of 106/82
d. temperature of 96.8
21. A hospitalized patient with a C7 Correct Answer: 4
cord injury begins to yell "I can't Rationale: Spinal shock is a condition almost half the people with acute spinal injury
feel my legs anymore." Which is the experience. It is characterized by a temporary loss of reflex function below level of injury,
most appropriate action by the and includes the following symptomatology: flaccid paralysis of skeletal muscles, loss of
nurse? sensation below the injury, and possibly bowel and bladder dysfunction and loss of ability to
1. Remind the patient of her injury perspire below the injury level. In this case, the nurse should explain to the patient what is
and try to comfort her. happening.
2. Call the healthcare provider and
get an order for radiologic
evaluation.
3. Prepare the patient for surgery,
as her condition is worsening.
4. Explain to the patient that this
could be a common, temporary
problem.
22. In counseling patient with spinal D. will probably be unable to have either psychogenic or reflexogenic erections with no
cord lesions regarding sexual ejaculation or orgasm
function, the nurse advises a male Rationale: Most patients with a complete lower motor neuron lesion are unable to have either
patient with a complete lower psychogenic or reflexogenic erections, and alterative methods of obtaining sexual satisfaction
motor neuron lesion that he may be suggested. Patients with incomplete lower motor neuron lesions have the highest
a. is most likely to have possibility of successful psychogenic erections with ejaculation, whereas patients with
reflexogenic erections and may incomplete upper motor neuron lesions are more likey to experience reflexogeic erections
experience orgasm if ejaculation with ejaculation. Patients with complete upper motor neuron lesions usually only have reflex
occurs sexual function with rare ejaculation.
b. may have uncontrolled reflex
erections, but that orgasm and
ejaculation are usually not possible
c. has a lesion with the greatest
possibility of successful
psychogenic erection with
ejaculation and orgasm
d. will probably be unable to have
either psychogenic or reflexogenic
erections with no ejaculation or
orgasm
23. An initial incomplete spinal cord C. c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
injury often results in complete Rationale: The primary injury of the spinal cord rarely affects the entire cord, but the patho of
cord damage because of secondary injury may result in damage that is the same as mechanical severance of the cord.
a. edematous compression of the Complete cord dissolution occurs through autodestruction of the cord by hemorrhage,
cord above the level of the injury edema, and the presence of metabolites and norepinephrine. resulting in anoxia and infarction
b. continued trauma to the cord of the cord. Edema resulting from the inflammatory response may increase the damage as it
resulting from damage to extends above and below the injury site.
stabilizing ligaments
c. infarction and necrosis of the
cord caused by edema,
hemorrhage, and metabolites
d. mecheanical transection of the
cord by sharp vertebral bone
fragments after the initial injury
24. In planning community education D. adolescent and young adult men
for prevention of spinal cord Rationale: Spinnal cord injuries are highest in young adult men between the ages of 15 and 30
injuries, the nurse targets and those who are impulsive or risk takers in daily living. Other risk factors include alcohol
a. elderly men and drug abuse as well as participation in sports and occupational exposure to trauma or
b. teenage girls violence.
c. elementary school-age children
d. adolescent and young adult
men
25. MULTIPLE RESPONSE Correct Answer: B, C, E, F
Rationale: The patient is at risk for bradycardia and poikilothermia caused by sympathetic
1. When caring for a patient who nervous system dysfunction and should have continuous cardiac monitoring and maintenance
experienced a T1 spinal cord of a relatively warm room temperature. Gastrointestinal (GI) motility is decreased initially and
transsection 2 days ago, which NG suctioning is indicated. To avoid bladder distension, a retention catheter is used during this
collaborative and nursing actions acute phase. Stress ulcers are a common complication but can be avoided through the use of
will the nurse include in the plan the H2 receptor blockers such as famotidine.
of care? (Select all that apply.)
a. Endotracheal suctioning Cognitive Level: Application Text Reference: pp. 1594-1595, 1597, 1603
b. Continuous cardiac monitoring Nursing Process: Planning NCLEX: Physiological Integrity
c. Avoidance of cool room
temperature
d. Nasogastric tube feeding
e. Retention catheter care
f. Administration of H2 receptor
blockers
26. A nurse is caring for a client who a. condom catheter
experienced a cervical spine injury Rationale: a client who has a cervical spinal cord injury will also have a upper motor neuron
3 months ago. Which of the injury, which is manifested by a spastic bladder. because the bladder will empty on its own, a
following types of bladder condom catheter is an appropriate method and is noninvasive.
management methods should the B & C are for flaccid bladder.
nurse use for this client?
a. condom catheter
b. intermittent urinary
catheterization
c. crede's method
d. indwelling urinary catheter
27. A nurse is caring for a client who experienced a D. muscle relaxants
cervical spine injury 24 hours ago. which of the Rationale: The client will still be in spinal shock 24 hours following the injury.
following types of prescribed medications should the client will not experience muscle spasms until after the spinal shock has
the nurse clarify with the provider? resolved, making muscle relaxants unnecessary at this time.
a. glucocorticoids
b. plasma expanders
c. H2 antagonists
d. muscle relaxants
28. A nurse is caring for a client who has a C4 spinal D. respiratory compromise
cord injury. which of the following should the Rationale: Using the airway, breathing and circulation priority framework, the
nurse recognize the client as being at the greatest risk to the client with a SCI at the level of C4 is respiratory
greatest risk for? compromise secondary to involvement of the phrenic nerve. Maintainance of an
a. neurogenic shock airway and provision of ventilator support as needed is the priority intervention.
b. paralytic ileus
c. stress ulcer
d. respiratory compromise
29. A nurse is caring for a client with a spinal cord B. sit the client upright in bed
injury who reports a severe headache and is Rationale: The greatest risk to the client is experiencing a cerebrovascular
sweating profusely. vital signs include BP accident (stroke) secondary to elevated BP. The first action by the nurse is
220/110, apical heart rate of 54/min. Which of the elevate the head of the bed until the client is in an upright position. this will
following acctions should the nurse take first? lower the BP secondary to postural hypotension.
a. notify the provider
b. sit the client upright in bed
c. check the client's urinary catheter for
blockage
d. administer antihypertensive medication
30. A nurse is caring for a client with increased increased temp, decreased pulse, decreasing respirations, and increasing bp
intracranial pressure (ICP). the nurse should (a change in vital signs may be a late sign of increased ICP)
monitor for what vital signs that would occur if
ICP is rising
31. The nurse is caring for a patient with increased Correct Answer: 3
intracranial pressure (IICP). The nurse realizes Rationale: Suctioning further increases intracranial pressure; therefore, suctioning
that some nursing actions are contraindicated should be done to maintain a patent airway but not as a matter of routine.
with IICP. Which nursing action should be Maintaining patient comfort by frequent repositioning as well as keeping the
avoided? head elevated 30 degrees will help to prevent (or even reduce) IICP. Keeping
1. Reposition the patient every two hours. the patient properly oxygenated may also help to control ICP.
2. Position the patient with the head elevated 30
degrees.
3. Suction the airway every two hours per
standing orders.
4. Provide continuous oxygen as ordered.
32. The nurse is educating a patient and the Correct Answer: 2
family about different types of stabilization Rationale: A halo device will allow the patient to be mobile since it does not
devices. Which statement by the patient require weights like the Gardner-Wells tongs. The patient's pain level is not
indicates that the patient understands the dependant on the type of stabilization device used. The patient does not have a
benefit of using a halo fixation device instead great risk of infection with the Garnder-Wells tongs; both devices require pins to be
of Gardner-Wells tongs? inserted into the skull. The time required for stabilization is not dependant on the
1. "I will have less pain if I use the halo type of stabilization device used.
device."
2. "The halo device will allow me to get out of
bed."
3. "I am less likely to get an infection with the
halo device."
4. "The halo device does not have to stay in
place as long."
33. A nurse is planning care for a client who A. prevention of further damage to the spinal cord
suffered a spinal cord injury (SCI) involving a Rationale: The greatest risk to the client during the acute phase of a SCI is further
T12 fracture 1 week ago. The client has no damage to the spinal cord. Therefore, when planning care, the priority should be
muscle control of the lower limbs, bowel, or the prevention of further damage to the spinal cord by administration of
bladder. which of the following should be the corticosteroids, minimizing movement of the client until spinal stabilization is
nurses' greatest priority? accomplished through either traction or surgery, and adequate oxygenation of the
a. prevention of further damage to the spinal client to decrease ischemia of the spinal cord.
cord
b. prevention of contractures of the lower
extremities
c. prevention of skin breakdown of areas that
lack sensation
d. prevention of postural hypotension when
placing the client in a wheelchair
34. A nurse is positioning a client with increased B. head turned to the side
ICP. Which position would the nurse avoid? (The head of a client with increased ICP should be positioned so that the head is in
A. head midline a neutral, midline position. The nurse should avoid flexing or extending the neck or
B. head turned to the side turning the head side to side . The head of the bed should be raised 30-45 degrees
C. neck in neutral position . Use of proper position promotes venous drainage from the cranium to keep ICP
D. head of bed elevated 30-45 degrees down)
35. The nurse understands that when the spinal Correct Answer: 2
cord is injured, ischemia results and edema Rationale: Within 24 hours necrosis of both gray and white matter begins if
occurs. How should the nurse explain to the ischemia has been prolonged and the function of nerves passing through the
patient the reason that the extent of injury injured area is lost. Because the edema extends above and below the area affected,
cannot be determined for several days to a the extent of injury cannot be determined until after the edema is controlled.
week? Neurons do not regenerate, and the edema is the factor that limits the ability to
1. "Tissue repair does not begin for 72 hours." predict extent of injury.
2. "The edema extends the level of injury for
two cord segments above and below the
affected level."
3. "Neurons need time to regenerate so
stating the injury early is not predictive of
how the patient progresses."
4. "Necrosis of gray and white matter does
not occur until days after the injury."
36. One indication for surgical therapy of the
patient with a spinal cord injury is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are
torn
c. a high cervical injury causes loss of
respiratory function
d. evidence of continued compression of the
cord is apparent
37. One month after a spinal cord injury, which
finding is most important for you to monitor?
A. Bladder scan indicates 100 mL.
B. The left calf is 5 cm larger than the right
calf.
C. The heel has a reddened, nonblanchable
area.
D. Reflux bowel emptying.
38. The patient arrives in the emergency
department from a motor vehicle accident,
during which the car ran into a tree. The
patient was not wearing a seat belt, and the
windshield is shattered. What action is most
important for you to do?
A. Determine if the patient lost consciousness.
B. Assess the Glasgow Coma Scale (GCS)
score.
C. Obtain a set of vital signs.
D. Use a logroll technique when moving the
patient.
39. A patient has manifestations of autonomic
dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction
40. A patient is admitted to the emergency
department with a possible cervical spinal
cord injury following an automobile crash.
During the admission of the patient, the nurse
places the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other
injuries
c. maintaining immobilization of the cervical
spine
d. assessing the patient's motor and sensory
function
D. evidence of continued compression of the cord is apparent
Rationale: Although surgical treatment of spinal cord injuries often depends on the
preference of the health care provider, surgery is usually indicated when there is
continued compression of the cord by extrinsic forces or when there is evidence
of cord compression. Other indications may include progressive neurologic
deficit, compound fracture of the vertebra, bony fragments, and penetrating
wounds of the cord.
B. The left calf is 5 cm larger than the right calf.
Deep vein thrombosis is a common problem accompanying spinal cord injury
during the first 3 months. Pulmonary embolism is one of the leading causes of
death. Common signs and symptoms are absent. Assessment includes Doppler
examination and measurement of leg girth. The other options are not as urgent to
deal with as potential deep vein thrombosis.
D. Use a logroll technique when moving the patient.
When the head hits the windshield with enough force to shatter it, you must
assume neck or cervical spine trauma occurred and you need to maintain spinal
precautions. This includes moving the patient in alignment as a unit or using a
logroll technique during transfers. The other options are important and are done
after spinal precautions are applied.
Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing
allowing the bladder to become full, triggering massive vasoconstriction below
the injury site, producing the manifestations of this process. Acute symptoms of
autonomic dysreflexia, including a sustained elevated blood pressure, may
indicate fecal impaction. The other answers will not cause autonomic dysreflexia.
a. maintaining a patent airway
Rationale: The need for a patent airway is the first priority for any injured patient,
and a high cervical injury may decrease the gag reflex and ability to maintain an
airway, as well as the ability to breathe. Maintaining cervical stability is then a
consideration, along with assessing for other injuries and the patients neuro status.
41. A patient is admitted to the emergency department with a b. HR of 42 beats/min
spinal cord injury at the level of T2. Which of the following Rationale: Neurogenic shock associated with cord injuries above the
findings is of most concern to the nurse? level of T6 greatly decrease the effect of the sympathetic nervous
a. SpO2 of 92% system, and bradycardia and hypotension occur. A heart rate of 42 is
b. HR of 42 beats/min not adequate to meet oxygen needs of the body, and while low, the
c. BP of 88/60 BP is not at a critical point. The O2 sat is ok, and the motor and
d. loss of motor and sensory function in arms and legs sensory loss are expected.
42. A patient is admitted to the hospital with a CD4 spinal D. loss of sympathetic nervous system innervation resulting in
cord injury after a motorcycle collision. The patient's BP is peripheral vasodilation
83/49, and his pulse is 39 beats/min, and he remains orally
intubated. The nurse identifies this pathophysiologic
response as caused by
a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid paralysis
below the level of injury
c. loss of parasympathetic nervous system innervation
resulting in vasoconstriction
d. loss of sympathetic nervous system innervation
resulting in peripheral vasodilation
43. A patient is admitted with a spinal cord injury at the C7 B. tetraplegia with total sensory loss
level. During assessment the nurse identifies the presence Rationale: At the C7 level, spinal shock is manifested by tetraplegia
of spinal shock on finding and sensory loss. The neurologic loss may be temporary or
a. paraplegia with flaccid paralysis permanent. Paraplegia with sensory loss would occur at the level of
b. tetraplegia with total sensory loss T1. A hemiplegia occurs with central (brain) lesions affecting motor
c. total hemiplegia with sensory and motor loss neurons and spastic tetraplegia occurs when spinal shock resolves.
d. spastic tetraplegia with loss of pressure sensation
44. The patient is admitted with injuries that were sustained in Correct Answer: 2
a fall. During the nurse's first assessment upon admission, Rationale: Spinal shock is common in acute spinal cord injuries. In
the findings are: blood pressure 90/60 (as compared to addition to the signs and symptoms mentioned, the additional sign of
136/66 in the emergency department ), flaccid paralysis on absence of the cremasteric reflex is associated with spinal shock. Lack
the right, absent bowel sounds, zero urine output, and of respiratory effort is generally associated with high cervical injury.
palpation of a distended bladder. These signs are The findings describe paralysis that would be associated with spinal
consistent with which of the following? shock in an spinal injured patient. The likely cause of these findings is
1. paralysis not hypovolemia, but rather spinal shock.
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
45. A patient with a C7 spinal cord injury undergoing c. Take the patient's BP
rehabilitation tells the nurse he must have the flu because
he has a bad headache and nausea. The initial action of the
nurse is to
a. call the physician
b. check the patient's temperature
c. take the patient's BP
d. elevate the HOB to 90 degrees
46. A patient with a Correct Answer: 2
spinal cord injury at Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a life-threatening
the T1 level situation that will require immediate intervention or the patient will die. The most common cause is an
complains of a overextended bladder or bowel. Symptoms include hypertension, headache, diaphoresis, bradycardia, visual
severe headache changes, anxiety, and nausea. A calm, soothing environment is fine, though not what the patient needs in this
and an "anxious case. The nurse should recognize this as an emergency and proceed accordingly. Once the assessment has
feeling." Which is been completed, the findings will need to be communicated to the healthcare provider.
the most
appropriate initial
reaction by the
nurse?
1. Try to calm the
patient and make
the environment
soothing.
2. Assess for a full
bladder.
3. Notify the
healthcare provider.
4. Prepare the
patient for
diagnostic
radiography.
47. A patient with a C. c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder
spinal cord injury Rationale: Spinal shock occurs in about half of all people with acute spinal cord injury. In spinal shock, the
has spinal shock. entire cord below the level of the lesion fails to function, resulting in a flaccid paralysis and hypomotility of
The nurse plans most processes without any reflex activity. Return of reflex activity signals the end of spinal shock.
care for the patient Sympathetic function is impaired belwo the level of the injury because sympathetic nerves leave the spinal
based on the cord at the thoracic and lumbar areas, and cranial parasympathetic nerves predominate in control over
knowledge that respirations, heart, and all vessels and organ below the injury. Neurogenic shock results from loss of vascular
a. rehabilitation tone caused by the injury and is manifested by hypotension, peripheral vasodilation, and decreased CO.
measures cannot be Rehab activities are not contraindicated during spainl shock and should be instituted if the patient's
initiated until spinal cardiopulmonary status is stable.
shock has resolved
b. the patient will
need continuous
monitoring for
hypotension,
tachycardia, and
hypoxemia
c. resolution of
spinal shock is
manifested by
spasticity,
hyperreflexia, and
reflex emptying of
the bladder
d. the patient will
have complete loss
of motor and
sensory functions
below the level of
the injury, but
autonomic functions
are not affected
48. A patient with a spinal cord injury is Correct Answer: 1
recovering from spinal shock. The Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord
nurse realizes that the patient injury (SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia.
should not develop a full bladder Track urinary output carefully. Routine use of bladder scanning can help prevent the
because what emergency condition occurrence. Other causes of autonomic dysreflexia are impacted stool and skin pressure.
can occur if it is not corrected Autonomic crisis, autonomic shutdown, and autonomic failure are not terms used to describe
quickly? common complications of spinal injury associated with bladder distension.
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure
49. A patient with a spinal cord injury Correct Answer: 4
(SCI) has complete paralysis of the Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete
upper extremities and complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the
paralysis of the lower part of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
body. The nurse should use which
medical term to adequately
describe this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
50. A patient with a spinal cord injury Correct Answer: 2,4,5
(SCI) is admitted to the unit and Rationale: The healthcare provider is responsible for initial applying of the traction device.
placed in traction. Which of the The weights on the traction device must not be changed without the order of a healthcare
following actions is the nurse provider. When caring for a patient in traction, the nurse is responsible for assessment and
responsible for when caring for this care of the skin due to the increased risk of skin breakdown. The patient in traction is likely to
patient? experience pain and the nurse is responsible for assessing this pain and administering the
Select all that apply. appropriate analgesic as ordered. Passive range of motion helps prevent contractures; this is
1. modifying the traction weights as often performed by a physical therapist or a nurse.
needed
2. assessing the patient's skin
integrity
3. applying the traction upon
admission
4. administering pain medication
5. providing passive range of
motion
51. A patient with paraplegia has B. b. how to perform intermittent self-catheterization
developed an irritable bladder with Rationale: Intermittent self cath five to six times a day is the recommended method of
reflex emptying. The nurse teaches bladder management for the patient with a spinal cord injury because it more closely mimics
the patient normal emptying and has less potential for infectinon. The patient and family should be
a. hygiene care for an indwelling taught the procedure using clean technique, and if the patient has use of the arms, self-cath is
urinary catheter use during the acute phase to prevent overdistention of the bladder and surgical urinary
b. how to perform intermittent self- diversions are used if urinary complications occur.
catheterization
c. to empty the bladder with
manual pelvic pressure in
coordination with reflex voiding
patterns
d. that a urinary diversion, such as
an ileal conduit, is the easiest way
to handle urinary elimination
52. Two days following a spinal cord B. the extent of your injury cannot be determined until the secondary injury to the cord is
injury, a patient asks continually resolved
about the extent of impairment Rationale: Until the edema and necrosis at the site of the injury are resolved in 72 hours to 1
that will result from the injury. The week after the injury, it is not possible to determine how much cord damage is present from the
best response by the nurse is, initial injury, how much secondary injury occurred, or how much the cord was damaged by
a. you will have more normal edema that extended above the level of the original injury. The return of reflexes signals only
function when spinal shock the end of spinal shock, and the reflexes may be inappropriate and excessive, causing spasms
resolves and the reflex arc returns that complicate rehab.
b. the extent of your injury cannot
be determined until the
secondary injury to the cord is
resolved
c. when your condition is more
stable, an MRI will be done that
can reveal the extent of the cord
damage
d. because long-term
rehabilitation can affect the return
of tunction, it will be years before
we can tell when the complete
effect will be
53. An unconscious patient receiving Correct Answer: 1,2,5
emergency care following an Rationale: In the emergency setting, all patients who have sustained a trauma to the head or
automobile crash accident has a spine, or are unconscious should be treated as though they have a spinal cord injury.
possible spinal cord injury. What Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent
guidelines for emergency care movement are all basic guidelines of emergency care. Placement on the ventilator and raising
will be followed? the head of the bed will be considered after admittance to the hospital.
Select all that apply.
1. Immobilize the neck using rolled
towels or a cervical collar.
2. The patient will be placed in a
supine position
3. The patient will be placed on a
ventilator.
4. The head of the bed will be
elevated.
5. The patient's head will be
secured with a belt or tape
secured to the stretcher.
54. Urinary function during the acute A. an indwelling catheterization
phase of spinal cord injury is
maintained with
a. an indwelling catheter
b. intermittent catheterization
c. insertion of a suprapubic
catheter
d. use of incontinent pads to
protect the skin
55. A week following a spinal cord B. the could be a really positive finding. can you show me the movement
injury at T2, a patient experiences Rationale: in 1 week following a spinal cord injury, there may be a resolution of the edema of
movement in his leg and tells the the injury and an end to spinal shock. When spinal shock ends, reflex movement and spasms
nurse he is recovering some will occur, which may be mistaken for return of function, but with the resolution of edema,
function. The nurses' best response some normal function may also occur. it is important when movement occurs to determine
to the patient is, whether the movement is voluntary and can be consciously controlled, which would indicate
a. it is really still too soon to know some return of function.
if you will have a return of function
b. the could be a really positive
finding. can you show me the
movement
c. that's wonderful. we will start
exercising your legs more
frequently now
d. im sorry, but the movement is
only a reflex and does not indicate
normal function
56. Which clinical manifestation do you A. Bradycardia
interpret as representing Neurogenic shock results from loss of vasomotor tone caused by injury and is characterized
neurogenic shock in a patient with by hypotension and bradycardia. Loss of sympathetic innervation causes peripheral
acute spinal cord injury? vasodilation, venous pooling, and a decreased cardiac output.
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses
57. Which is most important to A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
respond to in a patient presenting Neurogenic shock is a loss of vasomotor tone caused by injury, and it is characterized by
with a T3 spinal injury? hypotension and bradycardia. The loss of sympathetic nervous system innervations causes
A. Blood pressure of 88/60 mm Hg, peripheral vasodilation, venous pooling, and a decreased cardiac output. The other options
pulse of 56 beats/minute can be expected findings and are not as significant. Patients in neurogenic shock have pink and
B. Deep tendon reflexes of 1+, dry skin, instead of cold and clammy, but this sign is not as important as the vital signs.
muscle strength of 1+
C. Pain rated at 9
D. Warm, dry skin
58. Which of the following nursing Correct Answer: 4
actions is appropriate for Rationale: A patient who has undergone a laminectomy needs to be turned by log rolling to
preventing skin breakdown in a prevent pressure on the area of surgery. An air mattress will help prevent skin breakdown but
patient who has recently the patient still needs to be turned frequently. Placing pillows under the patient can help take
undergone a laminectomy? pressure off of one side but the patient still needs to change positions often. Teaching the
1. Provide the patient with an air patient to grasp the side rail will cause the spine to twist, which needs to be avoided.
mattress.
2. Place pillows under patient to
help patient turn.
3. Teach the patient to grasp the
side rail to turn.
4. Use the log roll to turn the
patient to the side.
59. Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while
intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
60. While caring for the patient with spinal cord injury (SCI),
the nurse elevates the head of the bed, removes
compression stockings, and continues to assess vital
signs every two to three minutes while searching for the
cause in order to prevent loss of consciousness or
death. By practicing these interventions, the nurse is
avoiding the most dangerous complication of autonomic
dysreflexia, which is which of the following?
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. tachycardia
61. Without surgical stabilization, immobilization and
traction of the patient with a cervical spinal cord injury
most frequently requires the use of
a. kinetic beds
b. hard cervical collars
c. skeletal traction with skull tongs
d. sternal-occipital-mandibular immobilizer (SOMI)
brace
Correct Answer: 1
Rationale: The three major risk factors for spinal cord injuries (SCI) are
age (young adults), gender (higher incidence in males), and alcohol or
drug abuse. Females tend to engage in less risk-taking behavior than
young men.
Correct Answer: 3
Rationale: Autonomic dysreflexia is an emergency that requires
immediate assessment and intervention to prevent complications of
extremely high blood pressure. Additional nursing assistance will be
needed and a colleague needs to reach the physician stat.
C. skeletal traction with skull tongs
Rationale: Cervical injuries usually require skeletal traction with the use
of Crutchfield, Vinke, or other types of skull tongs to immobilize the
cervical vertebrae, even if fracture has not occurred. Hard cervical
collars are used for minor injuries or for stabilization during emergency
transport of the patient. Sandbags are also used temporarily to stabilize
the neck during insertion of tongs or during diagnostic testing
immediately following the injury. Special turning or kinetic beds may be
used to turn and mobilize patients who are in cervical traction.