SCI
What is the priority nursing intervention when a patient has a potential spine injury?
A) Check the pulse
B)Stabilize the spinal cord
C)Check pedal pulses
D)Apply a warm blanket
B
Rationale:
stabilizing the spinal cord during an injury is crucial because it prevents further damage to the delicate nerve tissue within the spinal cord.
The anatomical structure located in the center of the thoracic cavity is the:
A.Mediastinum
B.Visceral pleura
C.Parietal pleura
D.Diaphragm
Explanation
The mediastinum is the central compartment of the thoracic cavity, where various structures, including the heart, vessels, esophagus, trachea, and other important organs, are housed.
Which clinical manifestation would the nurse interpret as a manifestation of neurogenic shock in a patient with acute spinal cord injury?
a. Bradycardia
b. Hypertension
c. Neurogenic spasticity
d. Bounding pedal pulses
A. Bradycardia
Rationale: Neurogenic shock is caused by the loss of vasomotor tone after injury and is characterized by bradycardia and hypotension.
The nurse cares for a patient who has just had a thoracentesis. Which assessment information obtained by the nurse is a priority to communicate to the health care provider?
a. Oxygen saturation is 88%.
b. Blood pressure is 145/90 mm Hg.
c. Respiratory rate is 22 breaths/minute when lying flat.
d. Pain level is 5 (on 0 to 10 scale) with a deep breath.
A. Oxygen saturation is 88%
Rationale: Because of the decrease in fluid in the lung, the oxygen saturation should return to baseline or normal above 90%
True or False? SCI can cause symptoms ranging from slight muscle weakness to complete loss of sensory and loss of function.
True
Rationale: SCI can be as complicated as complete paralysis or as minor as muscle weakness.
A patient with a spinal cord injury at the T1 level complains of a pounding headache and feeling anxious Which is the most appropriate initial reaction by the nurse?
1. Tell the patient to calm down
2. Assess for a full bladder.
3. Notify the physical therapist
4. Prepare the patient for intubation
Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher and is a life-threatening situation that will require immediate intervention or the patient will die. The most common cause is an overextended bladder or bowel.
A patient who has a "sucking chest wound," or an opening in the chest wall as a result of a gunshot, stabbing, or impalement, is said to have:
A.An open pneumothorax
B.A complex pneumothorax
C.A hemothorax
D.A pleural effusion
A
A patient with an opening in the chest wall, such as from a gunshot, stab wound, or impalement, resulting in a "sucking chest wound," can be said to have open pneumothorax
The nurse is caring for a patient with a spinal cord injury. The patient exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response?
a. hemodynamic changes related to tilt table positioning
b. deteriorating myelin sheath
c. distended large intestine
d. crushed spinal cord
C. Distended large intestine
Rationale: Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury.
The nurse is assisting a health care provider with the removal of a chest tube. The nurse should instruct the patient to take which action?
a. Exhale slowly
b. Stay very still
c. Inhale and exhale quickly
d. Perform the Valsalva maneuver
D. Perform the Valsalva maneuver
Rationale: When the chest tube is removed, the client is asked to perform the Valsalva maneuver (take a deep breath, exhale, and bear down). The tube is quickly withdrawn, and an air-tight dressing is taped in place. An alternative instruction is to ask the client to take a deep breath and hold the breath while the tube is removed.
Which of the following findings is of most concern in a patient admitted to the hospital with T2 spinal cord injury.
A. HR of 40 bpm
B. Loss of peripheral sensation
C. BP of 100/60
D. CRT >3
A. HR of 40 bpm or less
Rationale: Bradycardia is often the beginning sign of neurogenic shock.
What demographic is at the highest risk for SCI?
A) 18-21 year old men
B) 25-30 year old women
C) 40-50 year old men
D) 18-21 year old women
B
Rationale: Young men are most at risk due to risk-taking behavior and poor impulse control
The following is the name of a potentially fatal condition where air and pressure quickly build up in the pleural space and can cause a mediastinal shift if left untreated:
A.An open pneumothorax
B.A tension pneumothorax
C.An plain pneumothorax
D.A spontaneous pneumothorax
B
Rationale: A tension pneumothorax is a potentially life-threatening condition in which air and pressure rapidly accumulate in the pleural space. If left untreated, it can lead to a mediastinal shift, which can further compromise the function of the heart and lungs.
After a patient is treated for a spinal cord injury, the healthcare provider informs the family that the patient is a paraplegic. What is the best way for the nurse to explain to the family about paraplegia?
a. lower extremities are paralyzed
b. upper extremities are paralyzed
c. one side of the body is paralyzed
d. both lower and upper extremities are paralyzed
A. Lower extremities are paralyzed
Rationale: Both legs are typically paralyzed with paraplegia. The patient should still have function of arms neck and head movements.
The nurse is assessing a patient recovering from a motor vehicle crash. Which assessment finding indicates that the patient is experiencing a pneumothorax?
a. hyperresonance to percussion at the apex of the left lung
b. dullness to percussion at the base of the left lung
c. crackles throughout the left lung
d. shallow breathing
a. hyperresonance to percussion at the apex of the left lung
Rationale: In pneumothorax, the percussion tone is hyperresonant due to the trapped air in the pleural space.
Which of the following is a sign of spinal shock?
A. Tachycardia
B. Significant drop in BP
C. Significant raise in BP
D. Apnea
B. Significant drop in BP
Rationale: Signs and symptoms of spinal shock are significant drop in BP, absent bowel sounds, decreased or zero urine output, and distended bladder.
A patient suffering from a spinal cord injury (SCI) is completely paralyzed in both the upper and lower extremities. The nurse needs to be aware that the patient is experiencing?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
Correct Answer: 4
Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete paralysis of the lower part of the body
The nurse monitors a patient after chest tube placement for a hemopneumothorax. The nurse is most concerned if which assessment finding is observed?
a. A large air leak in the water-seal chamber
b. 400 mL of blood in the collection chamber
c. Complaint of pain with each deep inspiration
d. Subcutaneous emphysema at the insertion site
B. 400 mL of blood loss in the collection chamber
Rationale:
Due to the amount of blood loss, the patient is at risk for hypovolemic shock.
An incomplete SCI has a _______ chance at recovery, compared to a complete SCI.
A. Better
B. Worse
A. Better
Rationale: Incomplete SCIs have a better chance of recovery because they are less severe than complete SCIs.
The client had a right-sided chest tube inserted two (2) hours ago for a pneumothorax. Which action should the nurse take if there is no fluctuation (tidaling) in the water-seal compartment?
a. Obtain an order for a stat chest x-ray.
b. Increase the amount of wall suction.
c. Check the tubing for kinks or clots.
d. Monitor the client's pulse oximetry
c. Check the tubing for kinks or clots
Rationale: The chest tube should have tibaling, if there is not then the first thing the nurse should do is make sure the tube is not kinked off or make sure there are no clots present.
Which of the following age groups is most at risk for spinal cord injury?
A. Older female adults
B. Young male adults
C. Children
D. Neonates
Rationale: due to the increased risky behaviors displayed by younger male adults, they are more at risk for injury.
Which manifestations in a patient with a thoracic spinal cord injury (T4) should alert the nurse to possible autonomic dysreflexia?
a. Headache and rising blood pressure
b. Irregular respirations and shortness of breath
c. Decreased level of consciousness or hallucinations
d. Abdominal distention and absence of bowel sounds
A. Headache and rising blood pressure
Rationale: Manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic), a throbbing headache, bradycardia, and diaphoresis. Respiratory changes, decreased level of consciousness, and gastrointestinal complaints are not characteristic manifestations.
The nurse caring for a patient with a pneumothorax and who has had a chest tube inserted notes continuous gentle bubbling in the suction control chamber. What action is most appropriate?
a. Do nothing, because this is an expected finding
b. Check for an air leak because the bubbling should be intermittent
c. Increase the suction pressure so that the bubbling becomes vigorous
d. Immediately clamp the chest tube and notify the health care provider
A. Do nothing, because this is an expected finding.
Rationale: The continuous bubbling should be noted as a normal expected finding. Chest tubes should only be clamped to check for air leak or to change the drainage system completely.
Autonomic dysreflexia occurs in patients with injury at what level or higher?
A. T4
B. C4
C. T6
D. C6
C. T6
Rationale: Autonomic dysreflexia is seen in patient with SCI T6 or higher.
Which of the following is a LATE sign of the development of a tension pneumothorax?
a. Hypotension
b. Tachycardia
c. Tracheal deviation
d. Dyspnea
c. Tracheal deviation
Rationale: With a tension pneumothorax, you will see hypotension, tachycardia, and dyspnea as the early manifestations. A late sign of a tension pneumothorax is that the trachea will eventually shift to the unaffected side.
What assessment finding is common in patients with autonomic dysreflexia? SATA
A. Sustained hypertension
B. Diarrhea
C. Tachypnea
D. Apnea
E. Fecal impaction
A, E
Rationale: hypertension and fecal impaction are both signs and symptoms of dysreflexia and need to be treated immediately. This is a medical emergency.