SCI Core
This finding indicates spinal shock is still present.
What is flaccid paralysis?
The FIRST nursing action for autonomic dysreflexia.
What is sit them up?
This MS type involves gradual progression without clear relapses.
What is primary progressive MS?
This occurs within weeks of trauma and may include nightmares and anxiety.
What is acute stress disorder?
A stable patient needing help with toileting can be assigned to this team member.
What is the UAP?
This client should be seen first.
-a newly admitted trauma patient in spinal precautions
-COPD patient with SpO2 sats at 92%
-Chonic HTN patient with BP 148/89
What is a newly admitted trauma patient in spinal precautions?
This shock presents with hypotension and bradycardia after SCI.
What is neurogenic shock?
The nurse should check for this most common trigger of AD.
What is bladder distention (or bowel impaction)?
Symptoms worsening after heat exposure is best explained by this.
What is heat-related symptom exacerbation (Uhthoff’s phenomenon)?
Flashbacks, hypervigilance, and sleep disturbance indicate this disorder.
What is PTSD?
A stable MS patient needing routine medications can be assigned to this nurse.
What is the LPN?
This is the priority assessment for a high cervical spinal cord injury.
What is airway/breath sounds?
A C5 injury with weak cough and accessory muscle use indicates this priority problem.
What is altered breathing pattern?
This intervention for spasticity is unsafe and should NOT be included.
What is using restraints?
This new symptom requires immediate assessment in an MS patient.
What is new vision changes or speech difficulty?
A child reenacting trauma through play is demonstrating this.
What is normal trauma processing?
This type of care must always be performed by the RN.
What is assessment or evaluation?
This change in an MS patient requires immediate evaluation.
What is new neurological deficit?
An injury above T12 leads to this type of bladder.
What is spastic (hyperactive) bladder?
Name one intervention used to prevent contractures in SCI patients.
What is ROM exercises / splints / proper alignment / trochanter rolls?
This finding would cause the nurse to question giving fingolimod.
What is bradycardia?
The best therapeutic response to trauma is encouraging this.
What is expression of feelings?
This task is NOT appropriate to delegate to a UAP.
What is assessing (e.g., pin sites, neuro status)?
This medication side effect requires immediate follow-up.
What is hyperglycemia with steroids?
A long-term complication in older SCI patients due to immobility and bone loss.
What is fracture?
This shock presents with warm skin and bradycardia.
What is neurogenic shock?
This complication in a client on natalizumab requires immediate action.
What is new neurological changes (possible PML)?
This is the most effective therapy for trauma-related disorders.
What is cognitive behavioral therapy?
Which task is appropriate to delegate to the UAP or LPN?
Monitoring intake/output, assessing a new SCI, evaluating meds, or teaching?
What is monitoring intake and output?
This finding in SCI is an emergency.
What is severe hypertension with headache (autonomic dysreflexia)?