Spinal cord injury NCLEX questions
1. A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with
any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?
a. Apply anti-embolytic stockings prior to elevation of the head.
b. Avoid binders around the abdominal area.
c. Practice with the client raising the head in one smooth, quick motion.
d. Avoid vasopressor medication for 2 hours prior to the client sitting up.
2. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When
planning the patient’s care, what aspect of the patient’s neurologic and functional status should the nurse
consider?
a. The patient will be unable to use a wheelchair
b. The patient will be unable to swallow food
c. The patient will be continent of urine, but incontinent of bowel
d. The patient will require full assistance for all aspects of elimination
3. A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse
perform when a client with spinal trauma may not be able to cough?
a. Administer oxygen as prescribed
b. Use mechanical ventilation
c. Maintain a patent airway
d. Suction the airway
4. The nurse recognizes that a patient with a spinal cord injury is at risk for muscle spasticity. How can the nurse
best prevent this complication of spinal cord injury?
a. Position the client in high Fowler’s position while in bed
b. Support the knees with a pillow when the patient is in bed
c. Perform passive ROM exercises as ordered
d. Administer NSAIDs as ordered
5. For a patient with a spinal cord injury, why is it beneficial to administer oxygen to maintain a high partial pressure
of oxygen (PaO2)?
a. So the patient will not have respiratory arrest
b. Because hypoxemia can create or worsen a neurological deficit of the spinal cord
c. To increase cerebral perfusion pressure
d. To prevent secondary brain injury
6. A patient with a spinal cord injury is at risk or the development of UTIs. Which of the following would the nurse
instruct the client to report if the client is concerned a UTI is occurring?
a. Dark or amber colored urine
b. Cloudy, foul smelling urine
1. A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with
any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?
a. Apply anti-embolytic stockings prior to elevation of the head.
b. Avoid binders around the abdominal area.
c. Practice with the client raising the head in one smooth, quick motion.
d. Avoid vasopressor medication for 2 hours prior to the client sitting up.
2. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When
planning the patient’s care, what aspect of the patient’s neurologic and functional status should the nurse
consider?
a. The patient will be unable to use a wheelchair
b. The patient will be unable to swallow food
c. The patient will be continent of urine, but incontinent of bowel
d. The patient will require full assistance for all aspects of elimination
3. A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse
perform when a client with spinal trauma may not be able to cough?
a. Administer oxygen as prescribed
b. Use mechanical ventilation
c. Maintain a patent airway
d. Suction the airway
4. The nurse recognizes that a patient with a spinal cord injury is at risk for muscle spasticity. How can the nurse
best prevent this complication of spinal cord injury?
a. Position the client in high Fowler’s position while in bed
b. Support the knees with a pillow when the patient is in bed
c. Perform passive ROM exercises as ordered
d. Administer NSAIDs as ordered
5. For a patient with a spinal cord injury, why is it beneficial to administer oxygen to maintain a high partial pressure
of oxygen (PaO2)?
a. So the patient will not have respiratory arrest
b. Because hypoxemia can create or worsen a neurological deficit of the spinal cord
c. To increase cerebral perfusion pressure
d. To prevent secondary brain injury
6. A patient with a spinal cord injury is at risk or the development of UTIs. Which of the following would the nurse
instruct the client to report if the client is concerned a UTI is occurring?
a. Dark or amber colored urine
b. Cloudy, foul smelling urine
