NR 443 CHAPTER 29: SPINAL CORD
INJURY
Chapter 29: Spinal Cord Injury
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra?
a. Last thoracic
b. Second lumbar
c. First sacral
d. Coccygeal
ANS: B
The cord starts at the brainstem and extends to the second lumbar vertebra.
DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A
TOP: Anatomy and Physiology of the Central Nervous System (CNS)
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. On admission to the emergency department, a patient with a C5 compression fracture can move
only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is
permanent. What is the best response by the nurse?
a. “Yes. In all likelihood, the paralysis is probably permanent.”
b. “No. Significant recovery of function should occur in a few days.”
c. “It is too early to tell. When the spinal shock subsides, we will know more.”
d. “You should talk to your physician about things of that nature.”
ANS: C
Spinal shock caused by swelling may last from a few days to months, clouding the issue of the true
extent of the injury.
DIF: Cognitive Level: Application REF: p. 516 OBJ: 3
TOP: Spinal Shock KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. Which assessment would indicate the resolution of spinal shock?
a. Extension and rigidity in affected limbs
b. Spastic involuntary movements in affected limbs
c. Tingling and burning in affected limbs
d. Voluntary purposeful movements of affected limbs
ANS: B
Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Resolution of Spinal Shock KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which assessment leads the emergency department nurse to suspect that a patient’s spinal cord
injury (SCI) is below C4?
, a. Voluntary eye movement
b. Ability to blink the eyelids
c. Unlabored respiration
d. Ability to make a facial grimace
ANS: C
The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal function for
ventilation.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Level of SCIs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance
of the nurse’s hand. The patient is unable to perform this action. Where does this assessment
confirm that cord damage has occurred?
a. C4 to C5
b. L2 to L4
c. L5
d. S1
ANS: C
The muscle group that controls the feet is at L5.
DIF: Cognitive Level: Comprehension REF: p. 515-517 OBJ: 2
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. What technique should the nurse implement to move the impaired legs of a patient with an SCI to
avoid stimulation muscle spasm?
a. Firmly grasping the calf muscle and the thigh muscle
b. Manipulating the limb by supporting the knee and ankle joints
c. Holding the foot upright and slowly dragging the limb into position
d. Requesting assistance to support the calf and thigh
ANS: B
Undue muscle stimulation can cause spasticity. Using the joint locations to support limbs when
repositioning them reduces likelihood of spasticity.
DIF: Cognitive Level: Application REF: p. 516 OBJ: 3
TOP: Spasticity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should
his score be interpreted?
a. Weak contraction
b. Muscle movement when supported
c. Active muscle movement without support
d. Full, active range-of-motion exercises against resistance
ANS: B
A 2 on the muscle-grading scale means that muscular movement is observed when the limb is
supported.
INJURY
Chapter 29: Spinal Cord Injury
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra?
a. Last thoracic
b. Second lumbar
c. First sacral
d. Coccygeal
ANS: B
The cord starts at the brainstem and extends to the second lumbar vertebra.
DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A
TOP: Anatomy and Physiology of the Central Nervous System (CNS)
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. On admission to the emergency department, a patient with a C5 compression fracture can move
only his head and has flaccid paralysis of all extremities. The distraught family asks if the paralysis is
permanent. What is the best response by the nurse?
a. “Yes. In all likelihood, the paralysis is probably permanent.”
b. “No. Significant recovery of function should occur in a few days.”
c. “It is too early to tell. When the spinal shock subsides, we will know more.”
d. “You should talk to your physician about things of that nature.”
ANS: C
Spinal shock caused by swelling may last from a few days to months, clouding the issue of the true
extent of the injury.
DIF: Cognitive Level: Application REF: p. 516 OBJ: 3
TOP: Spinal Shock KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
3. Which assessment would indicate the resolution of spinal shock?
a. Extension and rigidity in affected limbs
b. Spastic involuntary movements in affected limbs
c. Tingling and burning in affected limbs
d. Voluntary purposeful movements of affected limbs
ANS: B
Spastic involuntary movements after a period of flaccid paralysis announce the end of spinal shock.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Resolution of Spinal Shock KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which assessment leads the emergency department nurse to suspect that a patient’s spinal cord
injury (SCI) is below C4?
, a. Voluntary eye movement
b. Ability to blink the eyelids
c. Unlabored respiration
d. Ability to make a facial grimace
ANS: C
The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal function for
ventilation.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Level of SCIs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the resistance
of the nurse’s hand. The patient is unable to perform this action. Where does this assessment
confirm that cord damage has occurred?
a. C4 to C5
b. L2 to L4
c. L5
d. S1
ANS: C
The muscle group that controls the feet is at L5.
DIF: Cognitive Level: Comprehension REF: p. 515-517 OBJ: 2
TOP: Neurologic Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
6. What technique should the nurse implement to move the impaired legs of a patient with an SCI to
avoid stimulation muscle spasm?
a. Firmly grasping the calf muscle and the thigh muscle
b. Manipulating the limb by supporting the knee and ankle joints
c. Holding the foot upright and slowly dragging the limb into position
d. Requesting assistance to support the calf and thigh
ANS: B
Undue muscle stimulation can cause spasticity. Using the joint locations to support limbs when
repositioning them reduces likelihood of spasticity.
DIF: Cognitive Level: Application REF: p. 516 OBJ: 3
TOP: Spasticity KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Basic Care and Comfort
7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How should
his score be interpreted?
a. Weak contraction
b. Muscle movement when supported
c. Active muscle movement without support
d. Full, active range-of-motion exercises against resistance
ANS: B
A 2 on the muscle-grading scale means that muscular movement is observed when the limb is
supported.
