Spinal Cord Injury
Clue: Injury at or above this cervical level can cause loss of spontaneous respiratory function and often requires mechanical ventilation.
Answer: What is C4 (injury at or above C3–C5)?
Clue: In the ASIA Impairment Scale, which grade (A–E) indicates a complete spinal cord injury?
Answer: What is ASIA A?
Clue: This is the first priority for a patient with a suspected acute spinal cord injury, both at the scene and on arrival to the emergency department.
Answer: What is maintaining airway, breathing, and circulation while keeping the spine in neutral alignment (cervical stabilization)?
Clue: Autonomic dysreflexia is a sudden, dangerous rise in blood pressure that happens in people with spinal cord injuries at or above this spinal level.
Answer: What is T6?
Clue: This is the most common cause of acute pancreatitis in many populations and should always be asked about during the nursing history.
Answer: What are gallstones (biliary disease) or heavy alcohol use?
Clue: This is the priority nursing intervention at the scene of a suspected spinal cord injury before the patient is moved.
Answer: What is maintaining airway and cervical spine stabilization in neutral alignment (manual in‑line stabilization, rigid collar, backboard)?
Clue: A patient has no motor function below the level of injury, but some sensory function remains, including in sacral segments. Which ASIA grade is this?
Answer: What is ASIA B (sensory incomplete)?
Clue: Patients with spinal cord injuries are at very high risk for pressure injuries. Name one key nursing intervention to help prevent them.
Answer: What is turning/repositioning regularly, using pressure‑relieving mattresses/cushions, keeping skin clean and dry, or doing frequent skin checks (any one)?
Clue: Name one common trigger that can cause autonomic dysreflexia in a person with a spinal cord injury.
Answer: What is a full bladder (urinary retention or blocked catheter), a full bowel (constipation/impaction), tight clothing, or skin irritation (any one)?
Clue: For a patient with acute pancreatitis, nursing intervention is used to “rest the pancreas” and decrease stimulation of pancreatic enzyme secretion.
Answer: What is keeping the patient NPO (nothing by mouth) and managing IV fluids as ordered?
Clue: A patient with a new thoracic spinal cord injury has flaccid paralysis, hypotension, bradycardia, and warm, dry skin below the lesion. Name this complication.
Answer: What is neurogenic shock?
Clue: When classifying a spinal cord injury, nurses and doctors check two main things in each body area: the ability to move and the ability to feel. What are these two functions called?
Answer: What are motor function and sensory function?
Clue: A patient with a high thoracic spinal cord injury has weak cough and shallow breathing. Name one important respiratory nursing intervention to help prevent pneumonia or atelectasis.
Answer: What is assisting with deep‑breathing and coughing exercises, using an incentive spirometer, elevating the head of bed, doing chest physiotherapy, or suctioning as needed (any one)?
Clue: You suspect autonomic dysreflexia in a patient with a high thoracic spinal cord injury. What is the first nursing action you should take?
Answer: What is sit the patient upright / raise the head of the bed?
Clue: Pain with acute pancreatitis is often severe and located in this area, sometimes radiating to the back. Name the typical pain location and one key nursing intervention to manage it.
Answer: What is epigastric or left upper quadrant pain, radiating to the back, and using interventions such as administering prescribed opioids, positioning for comfort (e.g., leaning forward, semi‑Fowler’s), and frequent pain assessments?
Clue: A patient with a T6 spinal cord injury suddenly develops a severe headache, very high blood pressure, flushed skin above the level of injury, and cool, pale skin below. What is this complication, and what is the first nursing action?
Answer: What is autonomic dysreflexia, and the first action is to sit the patient upright/raise the head of bed and then quickly look for and relieve the cause (e.g., bladder distention, fecal impaction)?
Clue: A person with a higher spinal cord injury has weakness or paralysis in both arms and both legs. What is this pattern of paralysis called?
Answer: What is tetraplegia (or quadriplegia)?
Clue: Using “CSF analysis” (Lewis, pp. 1446, 1831), describe one typical difference in CSF findings between bacterial meningitis and viral meningitis.
Answer: What is: bacterial meningitis shows high neutrophils, very high protein, low glucose, and often high opening pressure; viral meningitis shows lymphocytic predominance, mildly elevated protein, normal glucose, and more normal opening pressure?
Clue: After you sit the patient up for suspected autonomic dysreflexia, name two more immediate nursing actions to find and remove the cause.
Answer: *What are:
Clue: Fluid volume deficit is a major concern in acute pancreatitis. Name two nursing interventions to monitor and support the patient’s hemodynamic status.
Answer: What are monitoring vital signs (especially HR and BP) and urine output, assessing for signs of hypovolemia (dry mucous membranes, poor skin turgor), maintaining and titrating IV fluids as ordered, and daily weights (any two)?
Clue: Table 8.3 (Huether & McCance) describes several mechanisms used by pathogens to resist the immune system. Give one example of a specific immune evasion mechanism.
Answer: What is antigenic variation, production of proteases that degrade host IgA, formation of biofilms, inhibition of phagolysosome fusion, resistance to oxidative killing, or intracellular survival?
Clue: A person with a spinal cord injury can move and feel in the arms, but has no movement or feeling in both legs. What is this general pattern of paralysis called?
Answer: What is paraplegia?
Clue: A patient with a new spinal cord injury has no sensation or movement in their legs and is mostly on bedrest. Name one nursing intervention to reduce the risk of deep vein thrombosis (DVT).
Answer: What is applying compression stockings or pneumatic compression devices, performing range‑of‑motion exercises, encouraging movement as able, or giving anticoagulants as prescribed (any one)?
Clue: For a patient presenting with suspected bacterial meningitis, describe the key nursing priorities in the first hour of care.
Answer: *What are:
Clue: A patient with severe acute pancreatitis is at risk for respiratory compromise and systemic infection (e.g., sepsis). Describe two priority nursing interventions to detect and respond early to these complications.
Answer: *What are: