SPINAL CORD INJURY NCLEX
EXAM
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. - ANSWERS-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.
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. - ANSWERS-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.
Which clinical manifestation do you interpret as representing
neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - ANSWERS-A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by
injury and is characterized by hypotension and bradycardia. Loss of
sympathetic innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
17. A male client with a spinal cord injury is prone to experiencing
automatic dysreflexia. The nurse would avoid which of the following
measures to minimize the risk of recurrence?
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 -
ANSWERS-17. Answer D. The most frequent cause of autonomic
dysreflexia is a distended bladder. Straight catheterization should be
done every 4 to 6 hours, and foley catheters should be checked
,frequently to prevent kinks in the tubing. Constipation and fecal
impaction are other causes, so maintaining bowel regularity is
important. Other causes include stimulation of the skin from tactile,
thermal, or painful stimuli. The nurse administers care to minimize
risk in these areas.
A client with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse should avoid which measure to minimize the
risk of recurrence?
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 -
ANSWERS-4. limiting bladder cath to once q12h
(the most frequent cause of autonomic dysreflexia is a distended
bladder . Straight cath should be performed q4-6 hrs and foley cath
should be checked frequently for kinks in tubing . Constipation and
fecal impaction are other causes, so maintaining bowel irregularity is
important .
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?
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. - ANSWERS-
Correct Answer: 2
, Rationale: Autonomic dysreflexia occurs in patients with injury at
level T6 or higher, and is a life-threatening situation that will require
immediate intervention or the patient will die. The most common
cause is an overextended bladder or bowel. Symptoms include
hypertension, headache, diaphoresis, bradycardia, visual changes,
anxiety, and nausea. A calm, soothing environment is fine, though not
what the patient needs in this case. The nurse should recognize this as
an emergency and proceed accordingly. Once the assessment has been
completed, the findings will need to be communicated to the
healthcare provider.
A hospitalized patient with a C7 cord injury begins to yell "I can't feel
my legs anymore." Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
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. - ANSWERS-Correct Answer: 4
Rationale: Spinal shock is a condition almost half the people with
acute spinal injury experience. It is characterized by a temporary loss
of reflex function below level of injury, and includes the following
symptomatology: flaccid paralysis of skeletal muscles, loss of
sensation below the injury, and possibly bowel and bladder
dysfunction and loss of ability to perspire below the injury level. In
this case, the nurse should explain to the patient what is happening.
EXAM
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. - ANSWERS-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.
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. - ANSWERS-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.
Which clinical manifestation do you interpret as representing
neurogenic shock in a patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - ANSWERS-A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by
injury and is characterized by hypotension and bradycardia. Loss of
sympathetic innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
17. A male client with a spinal cord injury is prone to experiencing
automatic dysreflexia. The nurse would avoid which of the following
measures to minimize the risk of recurrence?
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 -
ANSWERS-17. Answer D. The most frequent cause of autonomic
dysreflexia is a distended bladder. Straight catheterization should be
done every 4 to 6 hours, and foley catheters should be checked
,frequently to prevent kinks in the tubing. Constipation and fecal
impaction are other causes, so maintaining bowel regularity is
important. Other causes include stimulation of the skin from tactile,
thermal, or painful stimuli. The nurse administers care to minimize
risk in these areas.
A client with a spinal cord injury is prone to experiencing autonomic
dysreflexia. The nurse should avoid which measure to minimize the
risk of recurrence?
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 -
ANSWERS-4. limiting bladder cath to once q12h
(the most frequent cause of autonomic dysreflexia is a distended
bladder . Straight cath should be performed q4-6 hrs and foley cath
should be checked frequently for kinks in tubing . Constipation and
fecal impaction are other causes, so maintaining bowel irregularity is
important .
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?
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. - ANSWERS-
Correct Answer: 2
, Rationale: Autonomic dysreflexia occurs in patients with injury at
level T6 or higher, and is a life-threatening situation that will require
immediate intervention or the patient will die. The most common
cause is an overextended bladder or bowel. Symptoms include
hypertension, headache, diaphoresis, bradycardia, visual changes,
anxiety, and nausea. A calm, soothing environment is fine, though not
what the patient needs in this case. The nurse should recognize this as
an emergency and proceed accordingly. Once the assessment has been
completed, the findings will need to be communicated to the
healthcare provider.
A hospitalized patient with a C7 cord injury begins to yell "I can't feel
my legs anymore." Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
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. - ANSWERS-Correct Answer: 4
Rationale: Spinal shock is a condition almost half the people with
acute spinal injury experience. It is characterized by a temporary loss
of reflex function below level of injury, and includes the following
symptomatology: flaccid paralysis of skeletal muscles, loss of
sensation below the injury, and possibly bowel and bladder
dysfunction and loss of ability to perspire below the injury level. In
this case, the nurse should explain to the patient what is happening.
