NUR 254- UNIT 2.3 EXAM QUIZZES
WITH 100% CORRECT ANSWERS .
how would the nurse "grade" muscle strength for a patient who was not able to move to some
resistance but not full resistance? - Correct Answer -4 (out of 5)
a patient paralyzed from the neck down is said to have what? - Correct Answer -quadraplegia
a patient with weakness from the waist down would be documented as what? - Correct
Answer -paraparesis
a patient with spinal cord injury <8 hours ago, present with hypotension, bradycardia, and
absent reflexes and flaccid paralysis below the level of injury. what complication is this
indicative of? - Correct Answer -spinal shock
the nurse would anticipate which electrolyte imbalance related to immobility for a patient
with a complete cord injury at T5? - Correct Answer -hypercalcemia
at what level will a patient with complete spinal cord injury be ventilator dependent? -
Correct Answer -C4 (above C5)
aside from ensuring ABCs, what should the priority intervention be for a patient with
suspected spinal cord injury? - Correct Answer -immobilization
a patient is at risk for autonomic dysreflexia. what are three things that could stimulate AD? -
Correct Answer -full bladder/bowel, skin irritation (tight clothing, SCDS, etc.), pressure areas
the patient with acute spinal cord injury is receiving high dose methylprednisolone. what is
the purpose for this medication? - Correct Answer -decrease inflammation and decrease
secondary injury to the spinal cord
1
, at what level of SCI will a patient be ventilator dependent? - Correct Answer -C4
above which level of injury would a patient be at high risk for neurogenic shock and AD? -
Correct Answer -T6
a patient is unable to move or feel from the waist down. what would this be documented as? -
Correct Answer -paraplegia
a patient should be suspected as having a SCI and should be immobilized until ruled out for
what reasons? - Correct Answer -head trauma, GSW near spinal column, fall, MVC
when explaining spinal shock to a family member what should the nurse say? - Correct
Answer -it is like a concussion of the spinal cord and will resolve over time with increasing
reflexes and then hyperactive reflexes
a nurse stops to help after witnessing an accident involving adolescent riding a motorcycle,
hitting a tree and being thrown 30 feet into a field. the adolescent reports that he is unable to
move his legs. while waiting for EMS, what should the nurse do? - Correct Answer -leave the
adolescent as he is, staying with him
the nurse auscultates closely for bowel sounds when assessing a patient with SCI because? -
Correct Answer -the complication of paralytic ileus
the family of a patient with a fresh spinal cord injury asks what the methylprednisolone
infusion is for. what should the nurse say? - Correct Answer -it is to decrease inflammation
and decrease further injury to the spinal cord secondary to inflammatory response after the
initial injury
after a fall, which manifestations would indicate a potential spinal cord injury and need to be
evaluated further? - Correct Answer -extreme pain/pressure in the neck or back, impaired
breathing after injury, oddly positioned neck or back, weakness, paresthesia
when distinguishing spinal shock from neurogenic shock, what may not occur with
neurogenic shock? - Correct Answer -flaccid paralysis
2
WITH 100% CORRECT ANSWERS .
how would the nurse "grade" muscle strength for a patient who was not able to move to some
resistance but not full resistance? - Correct Answer -4 (out of 5)
a patient paralyzed from the neck down is said to have what? - Correct Answer -quadraplegia
a patient with weakness from the waist down would be documented as what? - Correct
Answer -paraparesis
a patient with spinal cord injury <8 hours ago, present with hypotension, bradycardia, and
absent reflexes and flaccid paralysis below the level of injury. what complication is this
indicative of? - Correct Answer -spinal shock
the nurse would anticipate which electrolyte imbalance related to immobility for a patient
with a complete cord injury at T5? - Correct Answer -hypercalcemia
at what level will a patient with complete spinal cord injury be ventilator dependent? -
Correct Answer -C4 (above C5)
aside from ensuring ABCs, what should the priority intervention be for a patient with
suspected spinal cord injury? - Correct Answer -immobilization
a patient is at risk for autonomic dysreflexia. what are three things that could stimulate AD? -
Correct Answer -full bladder/bowel, skin irritation (tight clothing, SCDS, etc.), pressure areas
the patient with acute spinal cord injury is receiving high dose methylprednisolone. what is
the purpose for this medication? - Correct Answer -decrease inflammation and decrease
secondary injury to the spinal cord
1
, at what level of SCI will a patient be ventilator dependent? - Correct Answer -C4
above which level of injury would a patient be at high risk for neurogenic shock and AD? -
Correct Answer -T6
a patient is unable to move or feel from the waist down. what would this be documented as? -
Correct Answer -paraplegia
a patient should be suspected as having a SCI and should be immobilized until ruled out for
what reasons? - Correct Answer -head trauma, GSW near spinal column, fall, MVC
when explaining spinal shock to a family member what should the nurse say? - Correct
Answer -it is like a concussion of the spinal cord and will resolve over time with increasing
reflexes and then hyperactive reflexes
a nurse stops to help after witnessing an accident involving adolescent riding a motorcycle,
hitting a tree and being thrown 30 feet into a field. the adolescent reports that he is unable to
move his legs. while waiting for EMS, what should the nurse do? - Correct Answer -leave the
adolescent as he is, staying with him
the nurse auscultates closely for bowel sounds when assessing a patient with SCI because? -
Correct Answer -the complication of paralytic ileus
the family of a patient with a fresh spinal cord injury asks what the methylprednisolone
infusion is for. what should the nurse say? - Correct Answer -it is to decrease inflammation
and decrease further injury to the spinal cord secondary to inflammatory response after the
initial injury
after a fall, which manifestations would indicate a potential spinal cord injury and need to be
evaluated further? - Correct Answer -extreme pain/pressure in the neck or back, impaired
breathing after injury, oddly positioned neck or back, weakness, paresthesia
when distinguishing spinal shock from neurogenic shock, what may not occur with
neurogenic shock? - Correct Answer -flaccid paralysis
2
