Spinal Cord Injury NCLEX Exam Questions with Verified Answers
Correct Answer(s): B
The nurse is caring for a patient admitted with a spinal
About 50% of people with acute spinal cord injury expe-
cord injury following a motor vehicle accident. The patient
rience a temporary loss of reflexes, sensation, and motor
exhibits a complete loss of motor, sensory, and reflex
activity that is known as spinal shock. Central cord syn-
activity below the injury level. The nurse recognizes this
drome is manifested by motor and sensory loss greater
condition as which of the following?
in the upper extremities than the lower extremities. Ante-
A) Central cord syndrome
rior cord syndrome results in motor and sensory loss but
B) Spinal shock syndrome
not reflexes. Brown-Séquard syndrome is characterized by
C) Anterior cord syndrome
ipsilateral loss of motor function and contralateral loss of
D) Brown-Séquard
sensory function.
Which of the following clinical manifestations would the
Correct Answer(s): A
nurse interpret as representing neurogenic shock in a
Neurogenic shock is due to the loss of vasomotor tone
patient with acute spinal cord injury?
caused by injury and is characterized by hypotension and
A) Bradycardia
bradycardia. Loss of sympathetic innervation causes pe-
B) Hypertension
ripheral vasodilation, venous pooling, and a decreased
C) Neurogenic spasticity
cardiac output.
D) Bounding pedal pulses
The nurse is caring for a patient admitted 1 week ago
with an acute spinal cord injury. Which of the following
assessment findings would alert the nurse to the presence Correct Answer(s): D
of autonomic dysreflexia? Autonomic dysreflexia is related to reflex stimulation of the
A) Tachycardia sympathetic nervous system reflected by hypertension,
B) Hypotension bradycardia, throbbing headache, and diaphoresis.
C) Hot, dry skin
D) Throbbing headache
When planning care for a patient with a C5 spinal cord
injury, which nursing diagnosis is the highest priority? Correct Answer(s): D
A) Risk for impairment of tissue integrity caused by paral- Maintaining a patent airway is the most important goal for
ysis a patient with a high cervical fracture. Although all of these
B) Altered patterns of urinary elimination caused by
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, Spinal Cord Injury NCLEX Exam Questions with Verified Answers
quadriplegia
C) Altered family and individual coping caused by the are appropriate nursing diagnoses for a patient with a
extent of trauma spinal cord injury, respiratory needs are always the highest
D) Inettective airway clearance caused by high cervical priority. Remember the ABCs.
spinal cord injury
Which of the following signs and symptoms in a patient
Correct Answer(s): A
with a T4 spinal cord injury should alert the nurse to the
Among the manifestations of autonomic dysreflexia are
possibility of autonomic dysreflexia?
hypertension (up to 300 mm Hg systolic) and a throbbing
A) Headache and rising blood pressure
headache. Respiratory manifestations, decreased level of
B) Irregular respirations and shortness of breath
consciousness, and gastrointestinal manifestations are
C) Decreased level of consciousness or hallucinations
not characteristic.
D) Abdominal distention and absence of bowel sounds
Which of the following interventions should the nurse
Correct Answer(s): A
perform in the acute care of a patient with autonomic
Because the most common cause of autonomic dysreflexia
dysreflexia?
is bladder irritation, immediate catheterization to relieve
A) Urinary catheterization
bladder distention may be necessary. The patient should
B) Administration of benzodiazepines
be positioned upright. Benzodiazepines are contraindi-
C) Suctioning of the patient's upper airway
cated and suctioning is likely unnecessary.
D) Placement of the patient in the Trendelenburg position
Nurse is assessing a patient who has a spinal cord in-
jury?Which should the nurse include in the nervous sys-
tem assessment to determine the extent of the patient's Correct Answer (s): a, c, d, e
injury? the assessment to determine the level of spinal cord injury
select all that apply. includes analyzing the -vital sign, plantar reflexes, bilate-
a. vital sign real hand grasp, description of trauma.
b. romberg test Romberg test must be performed while standing there-
c. plantar reflexes fore not suitable for unstable patient
d. bilatereal hand grasps
e. description of trauma
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Correct Answer(s): B
The nurse is caring for a patient admitted with a spinal
About 50% of people with acute spinal cord injury expe-
cord injury following a motor vehicle accident. The patient
rience a temporary loss of reflexes, sensation, and motor
exhibits a complete loss of motor, sensory, and reflex
activity that is known as spinal shock. Central cord syn-
activity below the injury level. The nurse recognizes this
drome is manifested by motor and sensory loss greater
condition as which of the following?
in the upper extremities than the lower extremities. Ante-
A) Central cord syndrome
rior cord syndrome results in motor and sensory loss but
B) Spinal shock syndrome
not reflexes. Brown-Séquard syndrome is characterized by
C) Anterior cord syndrome
ipsilateral loss of motor function and contralateral loss of
D) Brown-Séquard
sensory function.
Which of the following clinical manifestations would the
Correct Answer(s): A
nurse interpret as representing neurogenic shock in a
Neurogenic shock is due to the loss of vasomotor tone
patient with acute spinal cord injury?
caused by injury and is characterized by hypotension and
A) Bradycardia
bradycardia. Loss of sympathetic innervation causes pe-
B) Hypertension
ripheral vasodilation, venous pooling, and a decreased
C) Neurogenic spasticity
cardiac output.
D) Bounding pedal pulses
The nurse is caring for a patient admitted 1 week ago
with an acute spinal cord injury. Which of the following
assessment findings would alert the nurse to the presence Correct Answer(s): D
of autonomic dysreflexia? Autonomic dysreflexia is related to reflex stimulation of the
A) Tachycardia sympathetic nervous system reflected by hypertension,
B) Hypotension bradycardia, throbbing headache, and diaphoresis.
C) Hot, dry skin
D) Throbbing headache
When planning care for a patient with a C5 spinal cord
injury, which nursing diagnosis is the highest priority? Correct Answer(s): D
A) Risk for impairment of tissue integrity caused by paral- Maintaining a patent airway is the most important goal for
ysis a patient with a high cervical fracture. Although all of these
B) Altered patterns of urinary elimination caused by
1/9
, Spinal Cord Injury NCLEX Exam Questions with Verified Answers
quadriplegia
C) Altered family and individual coping caused by the are appropriate nursing diagnoses for a patient with a
extent of trauma spinal cord injury, respiratory needs are always the highest
D) Inettective airway clearance caused by high cervical priority. Remember the ABCs.
spinal cord injury
Which of the following signs and symptoms in a patient
Correct Answer(s): A
with a T4 spinal cord injury should alert the nurse to the
Among the manifestations of autonomic dysreflexia are
possibility of autonomic dysreflexia?
hypertension (up to 300 mm Hg systolic) and a throbbing
A) Headache and rising blood pressure
headache. Respiratory manifestations, decreased level of
B) Irregular respirations and shortness of breath
consciousness, and gastrointestinal manifestations are
C) Decreased level of consciousness or hallucinations
not characteristic.
D) Abdominal distention and absence of bowel sounds
Which of the following interventions should the nurse
Correct Answer(s): A
perform in the acute care of a patient with autonomic
Because the most common cause of autonomic dysreflexia
dysreflexia?
is bladder irritation, immediate catheterization to relieve
A) Urinary catheterization
bladder distention may be necessary. The patient should
B) Administration of benzodiazepines
be positioned upright. Benzodiazepines are contraindi-
C) Suctioning of the patient's upper airway
cated and suctioning is likely unnecessary.
D) Placement of the patient in the Trendelenburg position
Nurse is assessing a patient who has a spinal cord in-
jury?Which should the nurse include in the nervous sys-
tem assessment to determine the extent of the patient's Correct Answer (s): a, c, d, e
injury? the assessment to determine the level of spinal cord injury
select all that apply. includes analyzing the -vital sign, plantar reflexes, bilate-
a. vital sign real hand grasp, description of trauma.
b. romberg test Romberg test must be performed while standing there-
c. plantar reflexes fore not suitable for unstable patient
d. bilatereal hand grasps
e. description of trauma
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