SPINAL CORD INJURY NCLEX QUESTIONS LATEST
VERSIONS REAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES|AGRADE.
The nurse is caring for a patient admitted with a spinal cord injury
following a motor vehicle accident. The patient exhibits a
complete loss of motor, sensory, and reflex activity below the
injury level. The nurse recognizes this condition as which of the
following?
A) Central cord syndrome
B) Spinal shock syndrome
C) Anterior cord syndrome
D) Brown-Séquard - ANSWER >>>>Correct Answer(s): B
About 50% of people with acute spinal cord injury experience a
temporary loss of reflexes, sensation, and motor activity that is
known as spinal shock. Central cord syndrome is manifested by
motor and sensory loss greater in the upper extremities than the
lower extremities. Anterior cord syndrome results in motor and
sensory loss but not reflexes. Brown-Séquard syndrome is
characterized by ipsilateral loss of motor function and
contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse
interpret as representing neurogenic shock in a patient with acute
spinal cord injury?
A) Bradycardia
B) Hypertension
, C) Neurogenic spasticity
D) Bounding pedal pulses - ANSWER >>>>Correct Answer(s): A
Neurogenic shock is due to the loss of vasomotor tone caused by
injury and is characterized by hypotension and bradycardia. Loss
of sympathetic innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an
acute spinal cord injury. Which of the following assessment
findings would alert the nurse to the presence of autonomic
dysreflexia?
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache - ANSWER >>>>Correct Answer(s): D
Autonomic dysreflexia is related to reflex stimulation of the
sympathetic nervous system reflected by hypertension,
bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury,
which nursing diagnosis is the highest priority?
A) Risk for impairment of tissue integrity caused by paralysis
B) Altered patterns of urinary elimination caused by quadriplegia
C) Altered family and individual coping caused by the extent of
trauma
D) Ineffective airway clearance caused by high cervical spinal
cord injury - ANSWER >>>>Correct Answer(s): D
Maintaining a patent airway is the most important goal for a
patient with a high cervical fracture. Although all of these are
appropriate nursing diagnoses for a patient with a spinal cord
injury, respiratory needs are always the highest priority.
Remember the ABCs.
, Which of the following signs and symptoms in a patient with a T4
spinal cord injury should alert the nurse to the possibility of
autonomic dysreflexia?
A) Headache and rising blood pressure
B) Irregular respirations and shortness of breath
C) Decreased level of consciousness or hallucinations
D) Abdominal distention and absence of bowel sounds -
ANSWER >>>>Correct Answer(s): A
Among the manifestations of autonomic dysreflexia are
hypertension (up to 300 mm Hg systolic) and a throbbing
headache. Respiratory manifestations, decreased level of
consciousness, and gastrointestinal manifestations are not
characteristic.
Which of the following interventions should the nurse perform in
the acute care of a patient with autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient's upper airway
D) Placement of the patient in the Trendelenburg position -
ANSWER >>>>Correct Answer(s): A
Because the most common cause of autonomic dysreflexia is
bladder irritation, immediate catheterization to relieve bladder
distention may be necessary. The patient should be positioned
upright. Benzodiazepines are contraindicated and suctioning is
likely unnecessary.
Nurse is assessing a patient who has a spinal cord injury?Which
should the nurse include in the nervous system assessment to
determine the extent of the patient's injury?
select all that apply.
a. vital sign
b. romberg test
c. plantar reflexes
d. bilatereal hand grasps
VERSIONS REAL EXAM QUESTIONS AND CORRECT
ANSWERS WITH RATIONALES|AGRADE.
The nurse is caring for a patient admitted with a spinal cord injury
following a motor vehicle accident. The patient exhibits a
complete loss of motor, sensory, and reflex activity below the
injury level. The nurse recognizes this condition as which of the
following?
A) Central cord syndrome
B) Spinal shock syndrome
C) Anterior cord syndrome
D) Brown-Séquard - ANSWER >>>>Correct Answer(s): B
About 50% of people with acute spinal cord injury experience a
temporary loss of reflexes, sensation, and motor activity that is
known as spinal shock. Central cord syndrome is manifested by
motor and sensory loss greater in the upper extremities than the
lower extremities. Anterior cord syndrome results in motor and
sensory loss but not reflexes. Brown-Séquard syndrome is
characterized by ipsilateral loss of motor function and
contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse
interpret as representing neurogenic shock in a patient with acute
spinal cord injury?
A) Bradycardia
B) Hypertension
, C) Neurogenic spasticity
D) Bounding pedal pulses - ANSWER >>>>Correct Answer(s): A
Neurogenic shock is due to the loss of vasomotor tone caused by
injury and is characterized by hypotension and bradycardia. Loss
of sympathetic innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an
acute spinal cord injury. Which of the following assessment
findings would alert the nurse to the presence of autonomic
dysreflexia?
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache - ANSWER >>>>Correct Answer(s): D
Autonomic dysreflexia is related to reflex stimulation of the
sympathetic nervous system reflected by hypertension,
bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury,
which nursing diagnosis is the highest priority?
A) Risk for impairment of tissue integrity caused by paralysis
B) Altered patterns of urinary elimination caused by quadriplegia
C) Altered family and individual coping caused by the extent of
trauma
D) Ineffective airway clearance caused by high cervical spinal
cord injury - ANSWER >>>>Correct Answer(s): D
Maintaining a patent airway is the most important goal for a
patient with a high cervical fracture. Although all of these are
appropriate nursing diagnoses for a patient with a spinal cord
injury, respiratory needs are always the highest priority.
Remember the ABCs.
, Which of the following signs and symptoms in a patient with a T4
spinal cord injury should alert the nurse to the possibility of
autonomic dysreflexia?
A) Headache and rising blood pressure
B) Irregular respirations and shortness of breath
C) Decreased level of consciousness or hallucinations
D) Abdominal distention and absence of bowel sounds -
ANSWER >>>>Correct Answer(s): A
Among the manifestations of autonomic dysreflexia are
hypertension (up to 300 mm Hg systolic) and a throbbing
headache. Respiratory manifestations, decreased level of
consciousness, and gastrointestinal manifestations are not
characteristic.
Which of the following interventions should the nurse perform in
the acute care of a patient with autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient's upper airway
D) Placement of the patient in the Trendelenburg position -
ANSWER >>>>Correct Answer(s): A
Because the most common cause of autonomic dysreflexia is
bladder irritation, immediate catheterization to relieve bladder
distention may be necessary. The patient should be positioned
upright. Benzodiazepines are contraindicated and suctioning is
likely unnecessary.
Nurse is assessing a patient who has a spinal cord injury?Which
should the nurse include in the nervous system assessment to
determine the extent of the patient's injury?
select all that apply.
a. vital sign
b. romberg test
c. plantar reflexes
d. bilatereal hand grasps
