Spinal Cord Injury NCLEX Questions&
Answer With latest Updates Graded A
1. 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
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.
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
4. 35-year-old male who coaches a soccer team - ANSWER//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.
The nurse understands that when the spinal cord is injured, ischemia results and edema
occurs. How should the nurse explain to the patient the reason that the extent of injury
cannot be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
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." -
ANSWER//Correct Answer: 2
Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia
has been prolonged and the function of nerves passing through the injured area is lost.
Because the edema extends above and below the area affected, the extent of injury
cannot be determined until after the edema is controlled. Neurons do not regenerate,
and the edema is the factor that limits the ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities
and complete paralysis of the lower part of the body. The nurse should use which
medical term to adequately describe this in documentation?
, 1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia - ANSWER//Correct Answer: 4
Rationale: Quadriplegia describes complete paralysis of the upper extremities and
complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one
side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the
lower body.
Which of the following nursing actions is appropriate for preventing skin breakdown in a
patient who has recently undergone a laminectomy?
1. Provide the patient with an air 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. - ANSWER//Correct Answer: 4
Rationale: A patient who has undergone a laminectomy needs to be turned by log
rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin
breakdown but the patient still needs to be turned frequently. Placing pillows under the
patient can help take pressure off of one side but the patient still needs to change
positions often. Teaching the patient to grasp the side rail will cause the spine to twist,
which needs to be avoided.
The patient is admitted with injuries that were sustained in a fall. During the nurse's first
assessment upon admission, the findings are: blood pressure 90/60 (as compared to
136/66 in the emergency department), flaccid paralysis on the right, absent bowel
sounds, zero urine output, and palpation of a distended bladder. These signs are
consistent with which of the following?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia - ANSWER//Correct Answer: 2
Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs
and symptoms mentioned, the additional sign of absence of the cremasteric reflex is
associated with spinal shock. Lack of respiratory effort is generally associated with high
cervical injury. The findings describe paralysis that would be associated with spinal
shock in an spinal injured patient. The likely cause of these findings is not hypovolemia,
but rather spinal shock.
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
Answer With latest Updates Graded A
1. 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
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.
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
4. 35-year-old male who coaches a soccer team - ANSWER//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.
The nurse understands that when the spinal cord is injured, ischemia results and edema
occurs. How should the nurse explain to the patient the reason that the extent of injury
cannot be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
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." -
ANSWER//Correct Answer: 2
Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia
has been prolonged and the function of nerves passing through the injured area is lost.
Because the edema extends above and below the area affected, the extent of injury
cannot be determined until after the edema is controlled. Neurons do not regenerate,
and the edema is the factor that limits the ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities
and complete paralysis of the lower part of the body. The nurse should use which
medical term to adequately describe this in documentation?
, 1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia - ANSWER//Correct Answer: 4
Rationale: Quadriplegia describes complete paralysis of the upper extremities and
complete paralysis of the lower part of the body. Hemiplegia describes paralysis on one
side of the body. Paresthesia does not indicate paralysis. Paraplegia is paralysis of the
lower body.
Which of the following nursing actions is appropriate for preventing skin breakdown in a
patient who has recently undergone a laminectomy?
1. Provide the patient with an air 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. - ANSWER//Correct Answer: 4
Rationale: A patient who has undergone a laminectomy needs to be turned by log
rolling to prevent pressure on the area of surgery. An air mattress will help prevent skin
breakdown but the patient still needs to be turned frequently. Placing pillows under the
patient can help take pressure off of one side but the patient still needs to change
positions often. Teaching the patient to grasp the side rail will cause the spine to twist,
which needs to be avoided.
The patient is admitted with injuries that were sustained in a fall. During the nurse's first
assessment upon admission, the findings are: blood pressure 90/60 (as compared to
136/66 in the emergency department), flaccid paralysis on the right, absent bowel
sounds, zero urine output, and palpation of a distended bladder. These signs are
consistent with which of the following?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia - ANSWER//Correct Answer: 2
Rationale: Spinal shock is common in acute spinal cord injuries. In addition to the signs
and symptoms mentioned, the additional sign of absence of the cremasteric reflex is
associated with spinal shock. Lack of respiratory effort is generally associated with high
cervical injury. The findings describe paralysis that would be associated with spinal
shock in an spinal injured patient. The likely cause of these findings is not hypovolemia,
but rather spinal shock.
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
