SPINAL INJURY AND ICP NCLEX QUESTIONS
WITH CORRECT ANSWERS GRADED A+
LATEST UPDATE WITH RATIONALE
A patient has manifestations of autonomic dysreflexia. Which of these
assessments would indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction --ANSWER--Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing
allowing the bladder to become full, triggering massive vasoconstriction below
the injury site, producing the manifestations of this process. Acute symptoms of
autonomic dysreflexia, including a sustained elevated blood pressure, may
indicate fecal impaction. The other answers will not cause autonomic
dysreflexia.
A patient with a spinal cord injury is recovering from spinal shock. The nurse
realizes that the patient should not develop a full bladder because what
emergency condition can occur if it is not corrected quickly?
1. autonomic dysreflexia
Page 1 of 12
, 2. autonomic crisis
3. autonomic shutdown
4. autonomic failure --ANSWER--Correct Answer: 1
Rationale: Be attuned to the prevention of a distended bladder when caring for
spinal cord injury (SCI) patients in order to prevent this chain of events that lead
to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder
scanning can help prevent the occurrence. Other causes of autonomic
dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic
shutdown, and autonomic failure are not terms used to describe common
complications of spinal injury associated with bladder distension.
The nurse is educating a patient and the family about different types of
stabilization devices. Which statement by the patient indicates that the patient
understands the benefit of using a halo fixation device instead of Gardner-Wells
tongs?
1. "I will have less pain if I use the halo device."
2. "The halo device will allow me to get out of bed."
3. "I am less likely to get an infection with the halo device."
4. "The halo device does not have to stay in place as long." --ANSWER--
Correct Answer: 2
Rationale: A halo device will allow the patient to be mobile since it does not
require weights like the Gardner-Wells tongs. The patient's pain level is not
dependant on the type of stabilization device used. The patient does not have a
great risk of infection with the Garnder-Wells tongs; both devices require pins
Page 2 of 12
WITH CORRECT ANSWERS GRADED A+
LATEST UPDATE WITH RATIONALE
A patient has manifestations of autonomic dysreflexia. Which of these
assessments would indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction --ANSWER--Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing
allowing the bladder to become full, triggering massive vasoconstriction below
the injury site, producing the manifestations of this process. Acute symptoms of
autonomic dysreflexia, including a sustained elevated blood pressure, may
indicate fecal impaction. The other answers will not cause autonomic
dysreflexia.
A patient with a spinal cord injury is recovering from spinal shock. The nurse
realizes that the patient should not develop a full bladder because what
emergency condition can occur if it is not corrected quickly?
1. autonomic dysreflexia
Page 1 of 12
, 2. autonomic crisis
3. autonomic shutdown
4. autonomic failure --ANSWER--Correct Answer: 1
Rationale: Be attuned to the prevention of a distended bladder when caring for
spinal cord injury (SCI) patients in order to prevent this chain of events that lead
to autonomic dysreflexia. Track urinary output carefully. Routine use of bladder
scanning can help prevent the occurrence. Other causes of autonomic
dysreflexia are impacted stool and skin pressure. Autonomic crisis, autonomic
shutdown, and autonomic failure are not terms used to describe common
complications of spinal injury associated with bladder distension.
The nurse is educating a patient and the family about different types of
stabilization devices. Which statement by the patient indicates that the patient
understands the benefit of using a halo fixation device instead of Gardner-Wells
tongs?
1. "I will have less pain if I use the halo device."
2. "The halo device will allow me to get out of bed."
3. "I am less likely to get an infection with the halo device."
4. "The halo device does not have to stay in place as long." --ANSWER--
Correct Answer: 2
Rationale: A halo device will allow the patient to be mobile since it does not
require weights like the Gardner-Wells tongs. The patient's pain level is not
dependant on the type of stabilization device used. The patient does not have a
great risk of infection with the Garnder-Wells tongs; both devices require pins
Page 2 of 12
