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

Which area of the spinal cord falls within the sympathetic nervous system? ("Fight or Flight")

What is the T1-L2-L3 segment?

400

Which patient is at highest risk for a spinal cord injury?

An18-year-old male with a prior arrest for driving while intoxicated (DWI).

A 20-year-old female with a history of substance abuse.

A 50-year-old female with osteoporosis.

A 35-year-old male who plays on a competitive soccer team.

An18-year-old male with a prior arrest for driving while intoxicated (DWI).

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

The nurse is completing an assessment on a patient that has a spinal cord injury at T6 following a water-skiing accident four years ago. The patient is restless, sweaty and has facial flushing.  The patient's vital signs are: BP 144/98; HR 52/minute. The patient's last vitals signs were: BP 106/76; HR 72/minute. What action should the nurse take first?

Reassess the patient's blood pressure.

Check the patient's blood glucose.

Position the patient at 90 degrees (Fowlers).

Provide cooling blankets for the patient to lower their temperature.

Position the patient at 90 degrees (Fowlers).

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

A patient with a spinal cord injury at the T1 level complains of a severe headache and an "anxious feeling." Which is the most appropriate initial reaction by the nurse?

Try to calm the patient and make the environment soothing.

Assess for a full bladder.

Notify the healthcare provider.

Prepare the patient for diagnostic radiography.

Assess for a full bladder.

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

A 24-year-old patient was admitted to the medical unit for observation following a fall where their head hit the pavement quite hard.  The care plan wants the staff to watch for any signs of increased intracranial pressure.  Knowing this, which activities should the nurse encourage the patient avoid performing? (Select all that apply).

Coughing.

Sneezing.

Talking.

Valsalva maneuver.

Lying in bed with the head of bed at 45 degrees.

Coughing.

Sneezing.

Valsalva maneuver.

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 of the following diseases puts a patient most at risk for developing kidney disease?

Diabetes.

COPD.

Heart Failure.

Cystic Fibrosis.

Diabetes.

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.