Chapter 29: Spinal Cord Injury Linton: Introduction to Medical-Surgical Nursing, 6th Edition ALL ANSWERS 100% CORRECT SPRING FALL-2022 GUARANTEED GRADE A+

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 patients 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 nurses 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. DIF: Cognitive Level: Comprehension REF: p. 520 OBJ: 2 TOP: Neurologic Examination KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Basic Care and Comfort 8. Which technique of opening the airway in the newly admitted patient with an SCI is the most appropriate? a. Chin lift b. Head tilt c. Jaw thrust d. Neck flexion ANS: C The jaw thrust does not require spinal movement. DIF: Cognitive Level: Comprehension REF: p. 518 OBJ: 6 TOP: Opening Airway KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control 9. Brown-Squard syndrome results in which neurologic deficit? a. Bilateral loss of pain sensation below the level of injury b. Bilateral loss of temperature and motor function below the level of injury c. Motor and sensory loss in the upper extremities only d. Ipsilateral loss of motor function and contralateral loss of pain sensation and temperature ANS: D Brown-Squard syndrome is a hemisection of the cord resulting in ipsilateral motor loss and contralateral loss of pain and temperature. DIF: Cognitive Level: Knowledge REF: p. 515 OBJ: 3 TOP: Brown-Squard Syndrome KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 10. Which level of independence is an appropriate nursing care plan goal for a patient with a C8 transection? a. Manage a mechanical wheelchair with a joystick. b. Manage a mechanical wheelchair with hand control. c. Manage a specially equipped wheelchair. d. Manage an ordinary wheelchair. ANS: D Upper extremity mobility and enhanced hand grip allow the use of an ordinary wheelchair by an individual with a C8 level SCI. DIF: Cognitive Level: Application REF: p. 515 OBJ: 6 TOP: Goal for Rehabilitation KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 11. A paraplegic patient excitedly reports seeing his foot move when he was being turned. How is this phenomenon best explained? a. Reflexive movement b. Return of motor function c. Early symptom of autonomic dysreflexia d. Result of hypertonicity of the muscle ANS: A Reflexive action is a movement that does not require communication to the brain via the spinal cord. DIF: Cognitive Level: Comprehension REF: p. 511 OBJ: 5 TOP: Reflexive Motion KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 12. After spinal shock has been resolved, an indwelling catheter is removed. What way should the nurse expect this patient to empty the bladder? a. Manual expression (Cred method) b. Spontaneous reflexive action c. Normal voluntary control d. Self-catheterization ANS: B After spinal shock resolves, spasticity of the bladder causes spontaneous emptying. DIF: Cognitive Level: Comprehension REF: p. 516-517 OBJ: 6 TOP: Bladder Control KEY: Nursing Process Step: Planning MSC: NCLEX: Physiological Integrity: Physiological Adaptation 13. A distressed family member asks about the purpose of the Gardner-Wells tongs. Which is the most helpful explanation by the nurse regarding the action of Gardner-Wells tongs? a. Compress the cervical vertebrae. b. Immobilize the head. c. Allow the patient to be moved out of bed. d. Align the cervical vertebrae. ANS: D