SCI NCLEX Review Exam 2022 with complete solution
A client with a C6 spinal injury would most likely have which of the following
symptoms?
A: Aphasia
B: Hemiparesis
C:Paraplegia
D: Tetraplegia
D
Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of
injury to the thoracic cord and below.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following assessments would take priority?
A Bladder distension
B Neurological deficit
C pulse ox readings
D The client's feelings about the injury
C
After a spinal cord injury, ascending cord edema may cause a higher level of injury. The
diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and
ventilation is necessary. Although the other options would be necessary at a later time,
observation for respiratory failure is the priority.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40,
pulse 48, and RR of 18. The nurse suspects which of the following conditions?
A Autonomic dysreflexia
B Hemorrhagic shock
C Neurogenic shock
D Pulmonary embolism
C
Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin
due to the loss of adrenergic stimulation below the level of the lesion. Hypertension,
bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia.
Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't
be suspected without an injury. Pulmonary embolism presents with chest pain,
hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication
of spinal cord injury due to immobility.
A client is admitted with a spinal cord injury at the level of T12. He has limited
movement of his upper extremities. Which of the following medications would be
used to control edema of the spinal cord?
, A Acetazolamide (Diamox)
B Furosemide (Lasix)
C Methylprednisolone (Solu-Medrol)
D Sodium Bicarbonate
C
High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord
swelling and limit neurological deficit. The other drugs aren't indicated in this
circumstance.
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood
pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing
interventions should be done first?
A Place the client flat in bed
B Assess patency of the indwelling urinary catheter
C Give one SL nitroglycerin tablet
D raise the head of the bed immediately to 90 degrees
D
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and
bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious
stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat
will cause the blood pressure to increase even more. The indwelling urinary catheter
should be assessed immediately after the HOB is raised. Nitroglycerin is given to
reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of
the following reasons?
A To hasten wound healing
B To immobilize the cervical spine
C To prevent autonomic dysreflexia
D To hold bony fragments of the skull together
B
Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical
stabilization is accomplished.
Which of the following interventions describes an appropriate bladder program
for a client in rehabilitation for spinal cord injury?
A Insert an indwelling urinary catheter to straight drainage
B Schedule intermittent catheterization every 2 to 4 hours
C Perform a straight catheterization every 8 hours while awake
D Perform Crede's maneuver to the lower abdomen before the client voids.
B
A client with a C6 spinal injury would most likely have which of the following
symptoms?
A: Aphasia
B: Hemiparesis
C:Paraplegia
D: Tetraplegia
D
Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of
injury to the thoracic cord and below.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a
motorcycle accident. Which of the following assessments would take priority?
A Bladder distension
B Neurological deficit
C pulse ox readings
D The client's feelings about the injury
C
After a spinal cord injury, ascending cord edema may cause a higher level of injury. The
diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and
ventilation is necessary. Although the other options would be necessary at a later time,
observation for respiratory failure is the priority.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40,
pulse 48, and RR of 18. The nurse suspects which of the following conditions?
A Autonomic dysreflexia
B Hemorrhagic shock
C Neurogenic shock
D Pulmonary embolism
C
Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin
due to the loss of adrenergic stimulation below the level of the lesion. Hypertension,
bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia.
Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't
be suspected without an injury. Pulmonary embolism presents with chest pain,
hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication
of spinal cord injury due to immobility.
A client is admitted with a spinal cord injury at the level of T12. He has limited
movement of his upper extremities. Which of the following medications would be
used to control edema of the spinal cord?
, A Acetazolamide (Diamox)
B Furosemide (Lasix)
C Methylprednisolone (Solu-Medrol)
D Sodium Bicarbonate
C
High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord
swelling and limit neurological deficit. The other drugs aren't indicated in this
circumstance.
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood
pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing
interventions should be done first?
A Place the client flat in bed
B Assess patency of the indwelling urinary catheter
C Give one SL nitroglycerin tablet
D raise the head of the bed immediately to 90 degrees
D
Anxiety, flushing above the level of the lesion, piloerection, hypertension, and
bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious
stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat
will cause the blood pressure to increase even more. The indwelling urinary catheter
should be assessed immediately after the HOB is raised. Nitroglycerin is given to
reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of
the following reasons?
A To hasten wound healing
B To immobilize the cervical spine
C To prevent autonomic dysreflexia
D To hold bony fragments of the skull together
B
Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical
stabilization is accomplished.
Which of the following interventions describes an appropriate bladder program
for a client in rehabilitation for spinal cord injury?
A Insert an indwelling urinary catheter to straight drainage
B Schedule intermittent catheterization every 2 to 4 hours
C Perform a straight catheterization every 8 hours while awake
D Perform Crede's maneuver to the lower abdomen before the client voids.
B
