Spinal Cord Injury NCLEX Questions with Verified Answers Rated A
Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients with
injury at level T6 or higher, and is a life-threatening situ-
A patient with a spinal cord injury at the T1 level complains
ation that will require immediate intervention or the pa-
of a severe headache and an "anxious feeling." Which is
tient will die. The most common cause is an overextend-
the most appropriate initial reaction by the nurse?
ed bladder or bowel. Symptoms include hypertension,
1. Try to calm the patient and make the environment
headache, diaphoresis, bradycardia, visual changes, anx-
soothing.
iety, and nausea. A calm, soothing environment is fine,
2. Assess for a full bladder.
though not what the patient needs in this case. The nurse
3. Notify the healthcare provider.
should recognize this as an emergency and proceed ac-
4. Prepare the patient for diagnostic radiography.
cordingly. 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
Correct Answer: 4
yell "I can't feel my legs anymore." Which is the most
Rationale: Spinal shock is a condition almost half the peo-
appropriate action by the nurse?
ple with acute spinal injury experience. It is characterized
1. Remind the patient of her injury and try to comfort her.
by a temporary loss of reflex function below level of injury,
2. Call the healthcare provider and get an order for radi-
and includes the following symptomatology: flaccid paral-
ologic evaluation.
ysis of skeletal muscles, loss of sensation below the injury,
3. Prepare the patient for surgery, as her condition is
and possibly bowel and bladder dysfunction and loss of
worsening.
ability to perspire below the injury level. In this case, the
4. Explain to the patient that this could be a common,
nurse should explain to the patient what is happening.
temporary problem.
The nurse is caring for a patient with increased intracranial
Correct Answer: 3
pressure (IICP). The nurse realizes that some nursing ac-
Rationale: Suctioning further increases intracranial pres-
tions are contraindicated with IICP. Which nursing action
sure; therefore, suctioning should be done to maintain a
should be avoided?
patent airway but not as a matter of routine. Maintaining
1. Reposition the patient every two hours.
patient comfort by frequent repositioning as well as keep-
2. Position the patient with the head elevated 30 degrees.
ing the head elevated 30 degrees will help to prevent (or
3. Suction the airway every two hours per standing or-
, ders. even reduce) IICP. Keeping the patient properly oxygenat-
4. Provide continuous oxygen as ordered. ed may also help to control ICP.
Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial
A patient with a spinal cord injury (SCI) is admitted to the
applying of the traction device. The weights on the traction
unit and placed in traction. Which of the following actions
device must not be changed without the order of a health-
is the nurse responsible for when caring for this patient?
care provider. When caring for a patient in traction, the
Select all that apply.
nurse is responsible for assessment and care of the skin
1. modifying the traction weights as needed
due to the increased risk of skin breakdown. The patient
2. assessing the patient's skin integrity
in traction is likely to experience pain and the nurse is
3. applying the traction upon admission
responsible for assessing this pain and administering the
4. administering pain medication
appropriate analgesic as ordered. Passive range of motion
5. providing 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.
Correct Answer: 2,5
Which of these assessments would indicate a possible
Rationale: Autonomic dysreflexia can be caused by kinked
cause for this condition?
catheter tubing allowing the bladder to become full, trig-
Select all that apply.
gering massive vasoconstriction below the injury site, pro-
1. hypertension
ducing the manifestations of this process. Acute symptoms
2. kinked catheter tubing
of autonomic dysreflexia, including a sustained elevated
3. respiratory wheezes and stridor
blood pressure, may indicate fecal impaction. The other
4. diarrhea
answers will not cause autonomic dysreflexia.
5. fecal impaction
An unconscious patient receiving emergency care follow-
ing an automobile crash accident has a possible spinal Correct Answer: 1,2,5
cord injury. What guidelines for emergency care will be Rationale: In the emergency setting, all patients who have
followed? sustained a trauma to the head or spine, or are uncon-
Select all that apply. scious should be treated as though they have a spinal cord
1. Immobilize the neck using rolled towels or a cervical injury. Immobilizing the neck, maintaining a supine posi-
collar. tion and securing the patient's head to prevent movement
2. The patient will be placed in a supine position
, 3. The patient will be placed on a ventilator.
are all basic guidelines of emergency care. Placement on
4. The head of the bed will be elevated.
the ventilator and raising the head of the bed will be
5. The patient's head will be secured with a belt or tape
considered after admittance to the hospital.
secured to the stretcher.
Correct Answer: 1
Rationale: Be attuned to the prevention of a distended
A patient with a spinal cord injury is recovering from spinal
bladder when caring for spinal cord injury (SCI) patients in
shock. The nurse realizes that the patient should not de-
order to prevent this chain of events that lead to autonomic
velop a full bladder because what emergency condition
dysreflexia. Track urinary output carefully. Routine use of
can occur if it is not corrected quickly?
bladder scanning can help prevent the occurrence. Other
1. autonomic dysreflexia
causes of autonomic dysreflexia are impacted stool and
2. autonomic crisis
skin pressure. Autonomic crisis, autonomic shutdown, and
3. autonomic shutdown
autonomic failure are not terms used to describe common
4. autonomic failure
complications of spinal injury associated with bladder dis-
tension.
Which patient is at highest risk for a spinal cord injury?
Correct Answer: 1
1. 18-year-old male with a prior arrest for driving while
Rationale: The three major risk factors for spinal cord
intoxicated (DWI)
injuries (SCI) are age (young adults), gender (higher inci-
2. 20-year-old female with a history of substance abuse
dence in males), and alcohol or drug abuse. Females tend
3. 50-year-old female with osteoporosis
to engage in less risk-taking behavior than young men.
4. 35-year-old male who coaches a soccer team
The nurse understands that when the spinal cord is in- Correct Answer: 2
jured, ischemia results and edema occurs. How should the Rationale: Within 24 hours necrosis of both gray and white
nurse explain to the patient the reason that the extent of matter begins if ischemia has been prolonged and the
injury cannot be determined for several days to a week? function of nerves passing through the injured area is lost.
1. "Tissue repair does not begin for 72 hours." Because the edema extends above and below the area
2. "The edema extends the level of injury for two cord attected, the extent of injury cannot be determined until
segments above and below the attected level." after the edema is controlled. Neurons do not regenerate,
3. "Neurons need time to regenerate so stating the injury and the edema is the factor that limits the ability to predict
early is not predictive of how the patient progresses." extent of injury.
Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients with
injury at level T6 or higher, and is a life-threatening situ-
A patient with a spinal cord injury at the T1 level complains
ation that will require immediate intervention or the pa-
of a severe headache and an "anxious feeling." Which is
tient will die. The most common cause is an overextend-
the most appropriate initial reaction by the nurse?
ed bladder or bowel. Symptoms include hypertension,
1. Try to calm the patient and make the environment
headache, diaphoresis, bradycardia, visual changes, anx-
soothing.
iety, and nausea. A calm, soothing environment is fine,
2. Assess for a full bladder.
though not what the patient needs in this case. The nurse
3. Notify the healthcare provider.
should recognize this as an emergency and proceed ac-
4. Prepare the patient for diagnostic radiography.
cordingly. 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
Correct Answer: 4
yell "I can't feel my legs anymore." Which is the most
Rationale: Spinal shock is a condition almost half the peo-
appropriate action by the nurse?
ple with acute spinal injury experience. It is characterized
1. Remind the patient of her injury and try to comfort her.
by a temporary loss of reflex function below level of injury,
2. Call the healthcare provider and get an order for radi-
and includes the following symptomatology: flaccid paral-
ologic evaluation.
ysis of skeletal muscles, loss of sensation below the injury,
3. Prepare the patient for surgery, as her condition is
and possibly bowel and bladder dysfunction and loss of
worsening.
ability to perspire below the injury level. In this case, the
4. Explain to the patient that this could be a common,
nurse should explain to the patient what is happening.
temporary problem.
The nurse is caring for a patient with increased intracranial
Correct Answer: 3
pressure (IICP). The nurse realizes that some nursing ac-
Rationale: Suctioning further increases intracranial pres-
tions are contraindicated with IICP. Which nursing action
sure; therefore, suctioning should be done to maintain a
should be avoided?
patent airway but not as a matter of routine. Maintaining
1. Reposition the patient every two hours.
patient comfort by frequent repositioning as well as keep-
2. Position the patient with the head elevated 30 degrees.
ing the head elevated 30 degrees will help to prevent (or
3. Suction the airway every two hours per standing or-
, ders. even reduce) IICP. Keeping the patient properly oxygenat-
4. Provide continuous oxygen as ordered. ed may also help to control ICP.
Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial
A patient with a spinal cord injury (SCI) is admitted to the
applying of the traction device. The weights on the traction
unit and placed in traction. Which of the following actions
device must not be changed without the order of a health-
is the nurse responsible for when caring for this patient?
care provider. When caring for a patient in traction, the
Select all that apply.
nurse is responsible for assessment and care of the skin
1. modifying the traction weights as needed
due to the increased risk of skin breakdown. The patient
2. assessing the patient's skin integrity
in traction is likely to experience pain and the nurse is
3. applying the traction upon admission
responsible for assessing this pain and administering the
4. administering pain medication
appropriate analgesic as ordered. Passive range of motion
5. providing 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.
Correct Answer: 2,5
Which of these assessments would indicate a possible
Rationale: Autonomic dysreflexia can be caused by kinked
cause for this condition?
catheter tubing allowing the bladder to become full, trig-
Select all that apply.
gering massive vasoconstriction below the injury site, pro-
1. hypertension
ducing the manifestations of this process. Acute symptoms
2. kinked catheter tubing
of autonomic dysreflexia, including a sustained elevated
3. respiratory wheezes and stridor
blood pressure, may indicate fecal impaction. The other
4. diarrhea
answers will not cause autonomic dysreflexia.
5. fecal impaction
An unconscious patient receiving emergency care follow-
ing an automobile crash accident has a possible spinal Correct Answer: 1,2,5
cord injury. What guidelines for emergency care will be Rationale: In the emergency setting, all patients who have
followed? sustained a trauma to the head or spine, or are uncon-
Select all that apply. scious should be treated as though they have a spinal cord
1. Immobilize the neck using rolled towels or a cervical injury. Immobilizing the neck, maintaining a supine posi-
collar. tion and securing the patient's head to prevent movement
2. The patient will be placed in a supine position
, 3. The patient will be placed on a ventilator.
are all basic guidelines of emergency care. Placement on
4. The head of the bed will be elevated.
the ventilator and raising the head of the bed will be
5. The patient's head will be secured with a belt or tape
considered after admittance to the hospital.
secured to the stretcher.
Correct Answer: 1
Rationale: Be attuned to the prevention of a distended
A patient with a spinal cord injury is recovering from spinal
bladder when caring for spinal cord injury (SCI) patients in
shock. The nurse realizes that the patient should not de-
order to prevent this chain of events that lead to autonomic
velop a full bladder because what emergency condition
dysreflexia. Track urinary output carefully. Routine use of
can occur if it is not corrected quickly?
bladder scanning can help prevent the occurrence. Other
1. autonomic dysreflexia
causes of autonomic dysreflexia are impacted stool and
2. autonomic crisis
skin pressure. Autonomic crisis, autonomic shutdown, and
3. autonomic shutdown
autonomic failure are not terms used to describe common
4. autonomic failure
complications of spinal injury associated with bladder dis-
tension.
Which patient is at highest risk for a spinal cord injury?
Correct Answer: 1
1. 18-year-old male with a prior arrest for driving while
Rationale: The three major risk factors for spinal cord
intoxicated (DWI)
injuries (SCI) are age (young adults), gender (higher inci-
2. 20-year-old female with a history of substance abuse
dence in males), and alcohol or drug abuse. Females tend
3. 50-year-old female with osteoporosis
to engage in less risk-taking behavior than young men.
4. 35-year-old male who coaches a soccer team
The nurse understands that when the spinal cord is in- Correct Answer: 2
jured, ischemia results and edema occurs. How should the Rationale: Within 24 hours necrosis of both gray and white
nurse explain to the patient the reason that the extent of matter begins if ischemia has been prolonged and the
injury cannot be determined for several days to a week? function of nerves passing through the injured area is lost.
1. "Tissue repair does not begin for 72 hours." Because the edema extends above and below the area
2. "The edema extends the level of injury for two cord attected, the extent of injury cannot be determined until
segments above and below the attected level." after the edema is controlled. Neurons do not regenerate,
3. "Neurons need time to regenerate so stating the injury and the edema is the factor that limits the ability to predict
early is not predictive of how the patient progresses." extent of injury.
