SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS
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. - (answer) 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. - (answer) 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.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some
nursing actions are contraindicated with IICP. Which nursing action should be avoided?
1. Reposition the patient every two hours.
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. - (answer) Correct Answer: 3
,SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to
maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent
repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP.
Keeping the patient properly oxygenated may also help to control ICP.
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the
following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion - (answer) Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights
on the traction device must not be changed without the order of a healthcare provider. When caring for
a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased
risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for
assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion
helps prevent contractures; this is often performed by a physical therapist or a nurse.
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 - (answer) 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.
, SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS
An unconscious patient receiving emergency care following an automobile crash accident has a possible
spinal cord injury. What guidelines for emergency care will be followed?
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. - (answer) Correct
Answer: 1,2,5
Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or
are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck,
maintaining a supine position and securing the patient's head to prevent movement are all basic
guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be
considered after admittance to the hospital.
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?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure - (answer) Correct Answer: 1
Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI)
patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output
carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic
dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic
failure are not terms used to describe common complications of spinal injury associated with bladder
distension.
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
AND CORRECT ANSWERS
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. - (answer) 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. - (answer) 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.
The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse realizes that some
nursing actions are contraindicated with IICP. Which nursing action should be avoided?
1. Reposition the patient every two hours.
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. - (answer) Correct Answer: 3
,SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be done to
maintain a patent airway but not as a matter of routine. Maintaining patient comfort by frequent
repositioning as well as keeping the head elevated 30 degrees will help to prevent (or even reduce) IICP.
Keeping the patient properly oxygenated may also help to control ICP.
A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction. Which of the
following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion - (answer) Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial applying of the traction device. The weights
on the traction device must not be changed without the order of a healthcare provider. When caring for
a patient in traction, the nurse is responsible for assessment and care of the skin due to the increased
risk of skin breakdown. The patient in traction is likely to experience pain and the nurse is responsible for
assessing this pain and administering the appropriate analgesic as ordered. Passive range of motion
helps prevent contractures; this is often performed by a physical therapist or a nurse.
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 - (answer) 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.
, SPINAL CORD INJURY NCLEX QUESTIONS 2 LATEST VERSIONS 2023-2024 REAL EXAM 200+ QUESTIONS
AND CORRECT ANSWERS
An unconscious patient receiving emergency care following an automobile crash accident has a possible
spinal cord injury. What guidelines for emergency care will be followed?
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. - (answer) Correct
Answer: 1,2,5
Rationale: In the emergency setting, all patients who have sustained a trauma to the head or spine, or
are unconscious should be treated as though they have a spinal cord injury. Immobilizing the neck,
maintaining a supine position and securing the patient's head to prevent movement are all basic
guidelines of emergency care. Placement on the ventilator and raising the head of the bed will be
considered after admittance to the hospital.
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?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure - (answer) Correct Answer: 1
Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury (SCI)
patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track urinary output
carefully. Routine use of bladder scanning can help prevent the occurrence. Other causes of autonomic
dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic shutdown, and autonomic
failure are not terms used to describe common complications of spinal injury associated with bladder
distension.
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
