SPINAL CORD INJURY NCLEX EXAM QUESTIONS
WITH CORRECT DETAILED ANSWERS LATEST
UPDATE WITH EXPLANATIONS
Nurse is assessing a patient who has a spinal cord injury?Which should the
nurse include in the nervous system assessment to determine the extent of the
patient's injury?
select all that apply.
a. vital sign
b. romberg test
c. plantar reflexes
d. bilatereal hand grasps
e. description of trauma ---Correct Answer (s): a, c, d, e
the assessment to determine the level of spinal cord injury includes analyzing
the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma.
Romberg test must be performed while standing therefore not suitable for
unstable patient
A patient has impairments from a SCI at C4 classified as incomplete C on the
American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient
assessment is the nurse likely to observe in this patient?
A. poor propricopetor in the legs
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,B. poor peristalsis in the intestines
C. Absent gag and blinking reflexes
D. Absent bladder fulness sensation ---Answer is B
A patient who has a SCI has neurologic impairment to all extremities and the
diaphragm. However, because the injury is C on the ASIA impairment Scale,
sensory function can be intact but motor function will be impaired significantly
or absent.the patient can lose moderate to complete peristatlic action in the
intestines but should reatine the ability to sense bladder fulnessand the position
of the legs.
Which of the following interventions should the nurse perform in the acute care
of a patient with autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient's upper airway
D) Placement of the patient in the Trendelenburg position ---Correct
Answer(s): A
Because the most common cause of autonomic dysreflexia is bladder irritation,
immediate catheterization to relieve bladder distention may be necessary. The
patient should be positioned upright. Benzodiazepines are contraindicated and
suctioning is likely unnecessary.
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, The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion
to a male patient who has fractures of the cervical vertebrae. Which intervention
would prevent or detect adverse effects of the medication?
A. record pt baseline weight
B. adminster PPI( proton pump inhibitor)
C. Check the hear rate for bradycardia
D. suction the patient's oropharynx ---Correct Answer(s): B
the nurse should adminster PPI because they are at high risk for Gi erosion and
bleeding. from the steroid.
The nurse is caring for a patient admitted with a spinal cord injury following a
motor vehicle accident. The patient exhibits a complete loss of motor, sensory,
and reflex activity below the injury level. The nurse recognizes this condition as
which of the following?
A) Central cord syndrome
B) Spinal shock syndrome
C) Anterior cord syndrome
D) Brown-Séquard ---Correct Answer(s): B
About 50% of people with acute spinal cord injury experience a temporary loss
of reflexes, sensation, and motor activity that is known as spinal shock. Central
cord syndrome is manifested by motor and sensory loss greater in the upper
extremities than the lower extremities. Anterior cord syndrome results in motor
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WITH CORRECT DETAILED ANSWERS LATEST
UPDATE WITH EXPLANATIONS
Nurse is assessing a patient who has a spinal cord injury?Which should the
nurse include in the nervous system assessment to determine the extent of the
patient's injury?
select all that apply.
a. vital sign
b. romberg test
c. plantar reflexes
d. bilatereal hand grasps
e. description of trauma ---Correct Answer (s): a, c, d, e
the assessment to determine the level of spinal cord injury includes analyzing
the -vital sign, plantar reflexes, bilatereal hand grasp, description of trauma.
Romberg test must be performed while standing therefore not suitable for
unstable patient
A patient has impairments from a SCI at C4 classified as incomplete C on the
American Spinal Injury Association, (ASIA) Impairment Sclae. Which patient
assessment is the nurse likely to observe in this patient?
A. poor propricopetor in the legs
Page 1 of 16
,B. poor peristalsis in the intestines
C. Absent gag and blinking reflexes
D. Absent bladder fulness sensation ---Answer is B
A patient who has a SCI has neurologic impairment to all extremities and the
diaphragm. However, because the injury is C on the ASIA impairment Scale,
sensory function can be intact but motor function will be impaired significantly
or absent.the patient can lose moderate to complete peristatlic action in the
intestines but should reatine the ability to sense bladder fulnessand the position
of the legs.
Which of the following interventions should the nurse perform in the acute care
of a patient with autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient's upper airway
D) Placement of the patient in the Trendelenburg position ---Correct
Answer(s): A
Because the most common cause of autonomic dysreflexia is bladder irritation,
immediate catheterization to relieve bladder distention may be necessary. The
patient should be positioned upright. Benzodiazepines are contraindicated and
suctioning is likely unnecessary.
Page 2 of 16
, The nurse admnisters methylprenisone(Solu-Medrol) as a continous IV fusion
to a male patient who has fractures of the cervical vertebrae. Which intervention
would prevent or detect adverse effects of the medication?
A. record pt baseline weight
B. adminster PPI( proton pump inhibitor)
C. Check the hear rate for bradycardia
D. suction the patient's oropharynx ---Correct Answer(s): B
the nurse should adminster PPI because they are at high risk for Gi erosion and
bleeding. from the steroid.
The nurse is caring for a patient admitted with a spinal cord injury following a
motor vehicle accident. The patient exhibits a complete loss of motor, sensory,
and reflex activity below the injury level. The nurse recognizes this condition as
which of the following?
A) Central cord syndrome
B) Spinal shock syndrome
C) Anterior cord syndrome
D) Brown-Séquard ---Correct Answer(s): B
About 50% of people with acute spinal cord injury experience a temporary loss
of reflexes, sensation, and motor activity that is known as spinal shock. Central
cord syndrome is manifested by motor and sensory loss greater in the upper
extremities than the lower extremities. Anterior cord syndrome results in motor
Page 3 of 16
