Spinal Cord Injury NCLEX {Questions With 100% Correct
Answers} ()(Verified by Experts)
NCLEX — SPINAL CORD INJURY
QUESTIONS 11–20 (LONG • MOST TESTED • VERY TOUGH)
QUESTION 1 — Autonomic Dysreflexia vs Anxiety (VERY TESTED)
A patient with a T4 complete spinal cord injury suddenly complains of a severe pounding headache,
nasal congestion, and nausea. Assessment reveals BP 198/104 mmHg, HR 46, flushed skin above the
injury, and cool pale skin below.
What is the nurse’s PRIORITY action?
A. Administer prescribed antihypertensive medication
B. Place the patient in a supine position
C. Assess the urinary catheter for obstruction
D. Obtain a 12-lead ECG
✅ Correct Answer: C
Rationale:
This is autonomic dysreflexia (T6 or above).
✔ FIRST action = remove the triggering stimulus
✔ Most common cause = bladder distention / catheter blockage
Meds are used only if BP remains elevated after stimulus removal.
QUESTION 2 — Cervical SCI & Ventilatory Failure (HIGH PRIORITY)
A patient with a C2 spinal cord injury is admitted after a diving accident. Which finding requires
IMMEDIATE intervention?
A. Weak shoulder shrug
B. Absent gag reflex
,C. Respiratory rate of 10 with shallow breaths
D. Loss of sensation below the clavicles
✅ Correct Answer: C
Rationale:
C2 injury → high risk of respiratory failure
Airway and breathing override all neurological findings.
QUESTION 3 — Spinal Shock vs Neurogenic Shock (DIFFERENTIATION)
A trauma patient presents with flaccid paralysis, absent reflexes, hypotension, and warm dry skin. Heart
rate is 42 bpm.
Which condition BEST explains these findings?
A. Spinal shock
B. Neurogenic shock
C. Hypovolemic shock
D. Septic shock
✅ Correct Answer: B
Rationale:
✔ Neurogenic shock = hypotension + bradycardia + warm skin
✔ Spinal shock = flaccidity & areflexia without bradycardia
QUESTION 4 — Priority Positioning (VERY TESTED)
A patient with suspected spinal cord injury is brought to the emergency department on a backboard.
Which nursing action is MOST important?
A. Elevate the head of the bed
B. Maintain spinal immobilization
C. Assess bowel sounds
D. Apply sequential compression devices
✅ Correct Answer: B
Rationale:
Prevent secondary spinal cord injury.
Immobilization is critical until injury is ruled out.
QUESTION 5 — SATA: Autonomic Dysreflexia Manifestations
,Which findings are CONSISTENT with autonomic dysreflexia?
Select all that apply.
A. Severe headache
B. Bradycardia
C. Hypotension
D. Flushed skin above injury
E. Profuse sweating above injury
✅ Correct Answers: A, B, D, E
Rationale:
Autonomic dysreflexia =
✔ Severe hypertension
✔ Reflex bradycardia
✔ Flushing & sweating above injury
❌ Hypotension is incorrect
QUESTION 6 — Bowel Program Teaching (COMMON FAIL AREA)
A patient with a complete T8 spinal cord injury asks how bowel function will be managed.
Which statement by the nurse is MOST accurate?
A. “You will regain voluntary bowel control.”
B. “You will need a reflex bowel program.”
C. “You will require lifelong laxatives.”
D. “A colostomy will be necessary.”
✅ Correct Answer: B
Rationale:
Injuries above S2–S4 → reflex bowel
Scheduled bowel programs are required.
QUESTION 7 — Thermoregulation (ADVANCED NCLEX)
A patient with a high cervical spinal cord injury is at increased risk for poikilothermia because:
A. The hypothalamus is damaged
B. The patient cannot shiver below the injury
C. Sweating and vasoconstriction are impaired below the injury
D. Metabolic heat production is reduced
✅ Correct Answer: C
, Rationale:
SCI patients cannot regulate temperature below the level of injury
They depend on the environment to maintain body temperature.
QUESTION 8 — Preventing Autonomic Dysreflexia (PREVENTION FOCUS)
Which nursing intervention is MOST effective in preventing autonomic dysreflexia?
A. Maintaining strict blood pressure control
B. Providing frequent range-of-motion exercises
C. Ensuring regular bladder emptying
D. Limiting dietary sodium
✅ Correct Answer: C
Rationale:
✔ Bladder distention = #1 trigger
✔ Proper catheter care and scheduled emptying are essential
QUESTION 9 — Recovery Indicator (SPINAL SHOCK)
Which finding indicates that spinal shock is resolving?
A. Return of voluntary movement
B. Increasing muscle tone
C. Return of deep tendon reflexes
D. Improved blood pressure
✅ Correct Answer: C
Rationale:
✔ Return of reflexes = spinal shock resolving
Motor recovery may or may not occur.
QUESTION 10 — Priority Discharge Teaching (NCLEX FAVORITE)
A patient with a chronic spinal cord injury is preparing for discharge. Which instruction is MOST
important to include?
A. “Inspect your skin daily.”
B. “Limit fluid intake.”
C. “Avoid physical activity.”
D. “Check blood pressure weekly.”
✅ Correct Answer: A
Answers} ()(Verified by Experts)
NCLEX — SPINAL CORD INJURY
QUESTIONS 11–20 (LONG • MOST TESTED • VERY TOUGH)
QUESTION 1 — Autonomic Dysreflexia vs Anxiety (VERY TESTED)
A patient with a T4 complete spinal cord injury suddenly complains of a severe pounding headache,
nasal congestion, and nausea. Assessment reveals BP 198/104 mmHg, HR 46, flushed skin above the
injury, and cool pale skin below.
What is the nurse’s PRIORITY action?
A. Administer prescribed antihypertensive medication
B. Place the patient in a supine position
C. Assess the urinary catheter for obstruction
D. Obtain a 12-lead ECG
✅ Correct Answer: C
Rationale:
This is autonomic dysreflexia (T6 or above).
✔ FIRST action = remove the triggering stimulus
✔ Most common cause = bladder distention / catheter blockage
Meds are used only if BP remains elevated after stimulus removal.
QUESTION 2 — Cervical SCI & Ventilatory Failure (HIGH PRIORITY)
A patient with a C2 spinal cord injury is admitted after a diving accident. Which finding requires
IMMEDIATE intervention?
A. Weak shoulder shrug
B. Absent gag reflex
,C. Respiratory rate of 10 with shallow breaths
D. Loss of sensation below the clavicles
✅ Correct Answer: C
Rationale:
C2 injury → high risk of respiratory failure
Airway and breathing override all neurological findings.
QUESTION 3 — Spinal Shock vs Neurogenic Shock (DIFFERENTIATION)
A trauma patient presents with flaccid paralysis, absent reflexes, hypotension, and warm dry skin. Heart
rate is 42 bpm.
Which condition BEST explains these findings?
A. Spinal shock
B. Neurogenic shock
C. Hypovolemic shock
D. Septic shock
✅ Correct Answer: B
Rationale:
✔ Neurogenic shock = hypotension + bradycardia + warm skin
✔ Spinal shock = flaccidity & areflexia without bradycardia
QUESTION 4 — Priority Positioning (VERY TESTED)
A patient with suspected spinal cord injury is brought to the emergency department on a backboard.
Which nursing action is MOST important?
A. Elevate the head of the bed
B. Maintain spinal immobilization
C. Assess bowel sounds
D. Apply sequential compression devices
✅ Correct Answer: B
Rationale:
Prevent secondary spinal cord injury.
Immobilization is critical until injury is ruled out.
QUESTION 5 — SATA: Autonomic Dysreflexia Manifestations
,Which findings are CONSISTENT with autonomic dysreflexia?
Select all that apply.
A. Severe headache
B. Bradycardia
C. Hypotension
D. Flushed skin above injury
E. Profuse sweating above injury
✅ Correct Answers: A, B, D, E
Rationale:
Autonomic dysreflexia =
✔ Severe hypertension
✔ Reflex bradycardia
✔ Flushing & sweating above injury
❌ Hypotension is incorrect
QUESTION 6 — Bowel Program Teaching (COMMON FAIL AREA)
A patient with a complete T8 spinal cord injury asks how bowel function will be managed.
Which statement by the nurse is MOST accurate?
A. “You will regain voluntary bowel control.”
B. “You will need a reflex bowel program.”
C. “You will require lifelong laxatives.”
D. “A colostomy will be necessary.”
✅ Correct Answer: B
Rationale:
Injuries above S2–S4 → reflex bowel
Scheduled bowel programs are required.
QUESTION 7 — Thermoregulation (ADVANCED NCLEX)
A patient with a high cervical spinal cord injury is at increased risk for poikilothermia because:
A. The hypothalamus is damaged
B. The patient cannot shiver below the injury
C. Sweating and vasoconstriction are impaired below the injury
D. Metabolic heat production is reduced
✅ Correct Answer: C
, Rationale:
SCI patients cannot regulate temperature below the level of injury
They depend on the environment to maintain body temperature.
QUESTION 8 — Preventing Autonomic Dysreflexia (PREVENTION FOCUS)
Which nursing intervention is MOST effective in preventing autonomic dysreflexia?
A. Maintaining strict blood pressure control
B. Providing frequent range-of-motion exercises
C. Ensuring regular bladder emptying
D. Limiting dietary sodium
✅ Correct Answer: C
Rationale:
✔ Bladder distention = #1 trigger
✔ Proper catheter care and scheduled emptying are essential
QUESTION 9 — Recovery Indicator (SPINAL SHOCK)
Which finding indicates that spinal shock is resolving?
A. Return of voluntary movement
B. Increasing muscle tone
C. Return of deep tendon reflexes
D. Improved blood pressure
✅ Correct Answer: C
Rationale:
✔ Return of reflexes = spinal shock resolving
Motor recovery may or may not occur.
QUESTION 10 — Priority Discharge Teaching (NCLEX FAVORITE)
A patient with a chronic spinal cord injury is preparing for discharge. Which instruction is MOST
important to include?
A. “Inspect your skin daily.”
B. “Limit fluid intake.”
C. “Avoid physical activity.”
D. “Check blood pressure weekly.”
✅ Correct Answer: A
