SPINAL CORD INJURY

Etiology and Anatomy

100

Spinal cord injuries are more common in this gender.

What are males?

200

This is the most common cause of acute spinal cord injuries.

What are MVAs?

300

The nurse is caring for patient with an spinal injury at T4.  What assessment finding requires immediate notification of the healthcare provider (HCP)?

Changes in breathing, respiratory rate increases and O2 sat decreasing.

400

How many thoracic vertebrae are there?

12

Assessment

100

During assessment of a patient with SCI, the nurse determines that the patient has a poor cough with diaphragmatic breathing. Based on this finding, what should be the nurse's first action? A. Institute frequent turning and repositioning. B. Use tracheal suctioning to remove secretions. C. Assess lung sounds and respiratory rate and depth. D. Prepare the patient for endotracheal intubation and mechanical ventilation.

C. Because pneumonia and atelectasis are potential problems related to ineffective coughing and the loss of intercostal and abdominal muscle function, the nurse should assess the patient's breath sounds and respiratory function to determine whether secretions are being retained or whether there is progression of respiratory impairment.

200

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? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The client’s feelings about the injury

ANS: 3 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.

300

In assessing a client with a thoracic SCI, which clinical manifestation would the nurse expect to find to support the diagnosis of neurogenic shock? A. No reflex activity below the waist. B. Inability to move upper extremities. C. Complaints of a pounding headache. D. Hypotension and bradycardia.

A. Neurogenic shock associated with SCI represents a sudden depression of reflex activity below the level of injury.

400

The nurse is caring for clients on the rehab unit. Which clients should the nurse assess first after receiving the change-of-shift report? A. The client with a C6 SCI who is complaining of dyspnea and has crackles in the lungs. B. The client with an L4 SCI who is crying and is very upset about being discharged home. C. The client with an L2 SCI who is complaining of a headache and feeling very hot. D. The client with a T4 SCI who is unable to move the lower extremities.

A. This client has signs/symptoms of a respiratory complication and should be assessed first.

Care Plan

100

The client who has just undergone spinal surgery must be moved. How will the nurse plan to move this client? A. Getting the client up in a chair B. Keeping the client in the Trendelenburg position C. Lifting the client in unison with other health care personnel D. Log rolling the client

D.Log rolling the client Log rolling the client who has undergone spinal surgery is the best way to keep the spine in alignment.

200

What are the priorities of care in an acute phase of a SCI?

Preserve life and function, maintain alignment, prevent complications, support the client's and family's ability to cope.

300

The rehab nurse caring for the client with a lumbar SCI is developing the nursing care plan. Which intervention should the nurse implement? A. Keep oxygen via nasal cannula on at all times. B. Administer low-dose subcutaneous anticoagulants. C. Have the patient perform active lower extremity ROM exercises. D. Refer to a speech therapist for ventilator-assisted speech.

B. DVT is a potential complication of immobility, which can occur because the client cannot move the lower extremities as a result of the lumbar SCI. Low dose anticoagulation therapy helps prevent blood from coagulating, thereby preventing DVTs.

400

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. A. Keep the linens wrinkle-free under the client. B. Preventing unnecessary pressure on the lower limbs. C. Limiting bladder catheterization to once every 12 hours. D. Turning and repositioning the client at least every 2 hours. E. Ensuring that the client has a bowel movement at least once a week.

A, B, D The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4-6 hours, and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize the risk in these areas.

Teaching

100

A patient with paraplegia has developed an irritable bladder with reflex emptying. Along with possible use of medications, what will be most helpful for the nurse to teach the patient? A. Hygiene care for an indwelling urinary catheter. B. How to perform intermittent self-catheterization. C. To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns. D. That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary retention.

B. Intermittent self-acth 4-6 times a day is the recommended method of bladder management for the patient with a SCI and reflex neurogenic bladder because it more closely mimics normal emptying and has less potential for infection.

200

The client with a cervical factor is being discharged into a halo device. Which teaching instruction should the nurse discuss with the client? A. Discuss how to correctly remove the insertion pins. B. Instruct the client to report reddened or irritated skin areas. C. Inform the client that the vest liner cannot be changed. D. Encourage the client to remain in the recliner as much as possible

B. Reddened areas, especially under the brace, must be reported to the HCP because pressure ulcers can occur when wearing this appliance for an extended period.

300

The nurse is providing discharge instructions to a family whose child fell down the stairs causing a momentary blackout. Which statement by the family indicates a need for further instructions?

"She can have children's Tylenol every 4 – 6 hours for pain"   "She may complain of a headache for the first 24 hours"   "She must stay awake for the next 12 hours"   " She may be sensitive to light and sounds for the next 24 -48 hours"

"She must stay awake for the next 12 hours"

400

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? A. "I will use a straw for drinking." B. "I will drive only during the daytime." C. "I will be careful because the device alters balance." D. "I will wash the skin daily under the lamb's wool liner of the vest."

B. The client cannot drive at all because the device impairs range of vision.

General

100

What is the name of the condition in which the patient has a complete but temporary loss of motor, sensory, reflex, and autonomic function immediately after injury?

Spinal Shock (or spinal shock syndrome)

200

Which nursing task would be most appropriate for the nurse to delegate to the unlicensed nursing personnel? A. Teach Crede's maneuver to the client needing to void. B. Administer the tube feeding to the client who is quadriplegic. C. Assist with bowel training by placing the client on the bedside commode. D. Observe the client demonstrating self-catheterization technique.

C. The assistant can place the client on the bedside commode as part of the bowel training; the nurse is responsible for training but can delegate this task.

300

A patient is admitted to the ED with a SCI at the level of T2. Which finding is of most concern to the nurse? A. SpO2 of 92% B. HR of 42 bpm C. BP of 88/60 mmHg D. Loss of motor and sensory function in arms and legs.

B. Neurogenic shock associated with SCI above the level of T6 generally decreases the effect of the SNS and bradycardia and hypotension occur. A HR of 42 bpm is not adequate to meet the oxygen needs of the body.

400

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski’s reflex 4. Reflex emptying of the bladder

ANS: 3. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski’s reflex.