NUR 254- UNIT 2.3 EXAM QUESTIONS
AND CORRECT ANSWERS
a 24 year old with a history of a fall last year and resultant T1
injury is admitted for sever headache and nasal congestion. on
assessment, vital signs reveal bradycardia and hypertension. the
nurse determines which of the following is the probable cause of
his symptoms? - correct answer- distended bladder
a 30 year old male with a C-spine injury is placed in a halo vest
for which of the following reasons? - correct answer- to
immobilize the spine
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
a patient 2 months post T5 complete spinal cord injury, present
with sudden hypertension of 205-110 and complaints of
pounding headache. the upper body is flushed and diaphoretic.
what should the nurse do? - correct answer- assess for
,skin irritation, assess for fecal impaction, and remove all
restrictive clothing
a patient involved in an auto accident has severe spinal cord
injuries. if the patient is having difficulty with diaphragmatic
breathing, which level of the spinal cord is injured? - correct
answer- C6-C7
a patient is admitted with a C5 spinal cord injury. on admission,
what is the highest nursing priority intervention? - correct
answer- maintaining spinal cord precautions
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
a patient is unable to move or feel from the waist down. what
would this be documented as? - correct answer-
paraplegia
a patient paralyzed from the neck down is said to have what? -
correct answer- quadraplegia
, a patient reports the inability to move his or her neck. which
injury is the patient most likely to have incurred? - correct
answer- cervical injury
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
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
a patient with weakness from the waist down would be
documented as what? - correct answer- paraparesis
above which level of injury would a patient be at high risk for
neurogenic shock and AD? - correct answer- T6
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,
AND CORRECT ANSWERS
a 24 year old with a history of a fall last year and resultant T1
injury is admitted for sever headache and nasal congestion. on
assessment, vital signs reveal bradycardia and hypertension. the
nurse determines which of the following is the probable cause of
his symptoms? - correct answer- distended bladder
a 30 year old male with a C-spine injury is placed in a halo vest
for which of the following reasons? - correct answer- to
immobilize the spine
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
a patient 2 months post T5 complete spinal cord injury, present
with sudden hypertension of 205-110 and complaints of
pounding headache. the upper body is flushed and diaphoretic.
what should the nurse do? - correct answer- assess for
,skin irritation, assess for fecal impaction, and remove all
restrictive clothing
a patient involved in an auto accident has severe spinal cord
injuries. if the patient is having difficulty with diaphragmatic
breathing, which level of the spinal cord is injured? - correct
answer- C6-C7
a patient is admitted with a C5 spinal cord injury. on admission,
what is the highest nursing priority intervention? - correct
answer- maintaining spinal cord precautions
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
a patient is unable to move or feel from the waist down. what
would this be documented as? - correct answer-
paraplegia
a patient paralyzed from the neck down is said to have what? -
correct answer- quadraplegia
, a patient reports the inability to move his or her neck. which
injury is the patient most likely to have incurred? - correct
answer- cervical injury
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
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
a patient with weakness from the waist down would be
documented as what? - correct answer- paraparesis
above which level of injury would a patient be at high risk for
neurogenic shock and AD? - correct answer- T6
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,
