Spinal Cord Injury NCLEX {Questions
With 100% Correct Answers} (2026 /
2027)(Verified by Experts)
A patient with a spinal cord injury at level C3-4 is being cared for in the
ED. What is the priority assessment? - ✔✔✔ANSW✔✔..A
Determine the level at which the patient has intact sensation.
B
Assess the level at which the patient has retained mobility.
C
Check blood pressure and pulse for signs of spinal shock.
D
Monitor respiratory effort and oxygen saturation level.
A patient with a spinal cord injury has spinal shock. The nurse plans care
for the patient based on the knowledge that
a. rehabilitation measures cannot be initiated until spinal shock has
resolved
b. the patient will need continuous monitoring for hypotension,
tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia,
and reflex emptying of the bladder
d. the patient will have complete loss of motor and sensory functions
below the level of the injury, but autonomic functions are not affected -
✔✔✔ANSW✔✔..C. c. resolution of spinal shock is manifested by
spasticity, hyperreflexia, and reflex emptying of the bladder
Rationale: Spinal shock occurs in about half of all people with acute
spinal cord injury. In spinal shock, the entire cord below the level of the
lesion fails to function, resulting in a flaccid paralysis and hypomotility of
,most processes without any reflex activity. Return of reflex activity
signals the end of spinal shock. Sympathetic function is impaired belwo
the level of the injury because sympathetic nerves leave the spinal cord
at the thoracic and lumbar areas, and cranial parasympathetic nerves
predominate in control over respirations, heart, and all vessels and organ
below the injury. Neurogenic shock results from loss of vascular tone
caused by the injury and is manifested by hypotension, peripheral
vasodilation, and decreased CO. Rehab activities are not contraindicated
during spainl shock and should be instituted if the patient's
cardiopulmonary status is stable.
A patient with a C7 spinal cord injury undergoing rehabilitation tells the
nurse he must have the flu because he has a bad headache and nausea.
The initial action of the nurse is to
a. call the physician
b. check the patient's temperature
c. take the patient's BP
d. elevate the HOB to 90 degrees - ✔✔✔ANSW✔✔..c. Take the
patient's BP
One indication for surgical therapy of the patient with a spinal cord injury
is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical injury causes loss of respiratory function
d. evidence of continued compression of the cord is apparent -
✔✔✔ANSW✔✔..D. evidence of continued compression of the cord is
apparent
Rationale: Although surgical treatment of spinal cord injuries often
depends on the preference of the health care provider, surgery is usually
indicated when there is continued compression of the cord by extrinsic
forces or when there is evidence of cord compression. Other indications
,may include progressive neurologic deficit, compound fracture of the
vertebra, bony fragments, and penetrating wounds of the cord.
A patient is admitted to the emergency department with a possible
cervical spinal cord injury following an automobile crash. During the
admission of the patient, the nurse places the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory function -
✔✔✔ANSW✔✔..a. maintaining a patent airway
Rationale: The need for a patent airway is the first priority for any injured
patient, and a high cervical injury may decrease the gag reflex and ability
to maintain an airway, as well as the ability to breathe. Maintaining
cervical stability is then a consideration, along with assessing for other
injuries and the patients neuro status.
A nurse is planning care for a client who suffered a spinal cord injury
(SCI) involving a T12 fracture 1 week ago. The client has no muscle
control of the lower limbs, bowel, or bladder. which of the following
should be the nurses' greatest priority?
a. prevention of further damage to the spinal cord
b. prevention of contractures of the lower extremities
c. prevention of skin breakdown of areas that lack sensation
d. prevention of postural hypotension when placing the client in a
wheelchair - ✔✔✔ANSW✔✔..A. prevention of further damage to the
spinal cord
Rationale: The greatest risk to the client during the acute phase of a SCI
is further damage to the spinal cord. Therefore, when planning care, the
priority should be the prevention of further damage to the spinal cord by
administration of corticosteroids, minimizing movement of the client
until spinal stabilization is accomplished through either traction or
, surgery, and adequate oxygenation of the client to decrease ischemia of
the spinal cord.
Goals of rehabilitation for the patient with an injury at the C6 level
include (select all that apply)
a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair - ✔✔✔ANSW✔✔..B, C, D, E
A nurse is caring for a client who experienced a cervical spine injury 3
months ago. Which of the following types of bladder management
methods should the nurse use for this client?
a. condom catheter
b. intermittent urinary catheterization
c. crede's method
d. indwelling urinary catheter - ✔✔✔ANSW✔✔..a. condom catheter
Rationale: a client who has a cervical spinal cord injury will also have a
upper motor neuron injury, which is manifested by a spastic bladder.
because the bladder will empty on its own, a condom catheter is an
appropriate method and is noninvasive.
B & C are for flaccid bladder.
The nurse is caring for a patient admitted with a spinal cord injury
following a motor vehicle accident. The patient exhibits a complete loss
of motor, sensory, and reflex activity below the injury level. The nurse
recognizes this condition as which of the following?
A) Central cord syndrome
B) Spinal shock syndrome
With 100% Correct Answers} (2026 /
2027)(Verified by Experts)
A patient with a spinal cord injury at level C3-4 is being cared for in the
ED. What is the priority assessment? - ✔✔✔ANSW✔✔..A
Determine the level at which the patient has intact sensation.
B
Assess the level at which the patient has retained mobility.
C
Check blood pressure and pulse for signs of spinal shock.
D
Monitor respiratory effort and oxygen saturation level.
A patient with a spinal cord injury has spinal shock. The nurse plans care
for the patient based on the knowledge that
a. rehabilitation measures cannot be initiated until spinal shock has
resolved
b. the patient will need continuous monitoring for hypotension,
tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia,
and reflex emptying of the bladder
d. the patient will have complete loss of motor and sensory functions
below the level of the injury, but autonomic functions are not affected -
✔✔✔ANSW✔✔..C. c. resolution of spinal shock is manifested by
spasticity, hyperreflexia, and reflex emptying of the bladder
Rationale: Spinal shock occurs in about half of all people with acute
spinal cord injury. In spinal shock, the entire cord below the level of the
lesion fails to function, resulting in a flaccid paralysis and hypomotility of
,most processes without any reflex activity. Return of reflex activity
signals the end of spinal shock. Sympathetic function is impaired belwo
the level of the injury because sympathetic nerves leave the spinal cord
at the thoracic and lumbar areas, and cranial parasympathetic nerves
predominate in control over respirations, heart, and all vessels and organ
below the injury. Neurogenic shock results from loss of vascular tone
caused by the injury and is manifested by hypotension, peripheral
vasodilation, and decreased CO. Rehab activities are not contraindicated
during spainl shock and should be instituted if the patient's
cardiopulmonary status is stable.
A patient with a C7 spinal cord injury undergoing rehabilitation tells the
nurse he must have the flu because he has a bad headache and nausea.
The initial action of the nurse is to
a. call the physician
b. check the patient's temperature
c. take the patient's BP
d. elevate the HOB to 90 degrees - ✔✔✔ANSW✔✔..c. Take the
patient's BP
One indication for surgical therapy of the patient with a spinal cord injury
is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical injury causes loss of respiratory function
d. evidence of continued compression of the cord is apparent -
✔✔✔ANSW✔✔..D. evidence of continued compression of the cord is
apparent
Rationale: Although surgical treatment of spinal cord injuries often
depends on the preference of the health care provider, surgery is usually
indicated when there is continued compression of the cord by extrinsic
forces or when there is evidence of cord compression. Other indications
,may include progressive neurologic deficit, compound fracture of the
vertebra, bony fragments, and penetrating wounds of the cord.
A patient is admitted to the emergency department with a possible
cervical spinal cord injury following an automobile crash. During the
admission of the patient, the nurse places the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory function -
✔✔✔ANSW✔✔..a. maintaining a patent airway
Rationale: The need for a patent airway is the first priority for any injured
patient, and a high cervical injury may decrease the gag reflex and ability
to maintain an airway, as well as the ability to breathe. Maintaining
cervical stability is then a consideration, along with assessing for other
injuries and the patients neuro status.
A nurse is planning care for a client who suffered a spinal cord injury
(SCI) involving a T12 fracture 1 week ago. The client has no muscle
control of the lower limbs, bowel, or bladder. which of the following
should be the nurses' greatest priority?
a. prevention of further damage to the spinal cord
b. prevention of contractures of the lower extremities
c. prevention of skin breakdown of areas that lack sensation
d. prevention of postural hypotension when placing the client in a
wheelchair - ✔✔✔ANSW✔✔..A. prevention of further damage to the
spinal cord
Rationale: The greatest risk to the client during the acute phase of a SCI
is further damage to the spinal cord. Therefore, when planning care, the
priority should be the prevention of further damage to the spinal cord by
administration of corticosteroids, minimizing movement of the client
until spinal stabilization is accomplished through either traction or
, surgery, and adequate oxygenation of the client to decrease ischemia of
the spinal cord.
Goals of rehabilitation for the patient with an injury at the C6 level
include (select all that apply)
a. stand erect with leg brace
b. feed self with hand devices
c. drive an electric wheelchair
d. assist with transfer activities
e. drive adapted van from wheelchair - ✔✔✔ANSW✔✔..B, C, D, E
A nurse is caring for a client who experienced a cervical spine injury 3
months ago. Which of the following types of bladder management
methods should the nurse use for this client?
a. condom catheter
b. intermittent urinary catheterization
c. crede's method
d. indwelling urinary catheter - ✔✔✔ANSW✔✔..a. condom catheter
Rationale: a client who has a cervical spinal cord injury will also have a
upper motor neuron injury, which is manifested by a spastic bladder.
because the bladder will empty on its own, a condom catheter is an
appropriate method and is noninvasive.
B & C are for flaccid bladder.
The nurse is caring for a patient admitted with a spinal cord injury
following a motor vehicle accident. The patient exhibits a complete loss
of motor, sensory, and reflex activity below the injury level. The nurse
recognizes this condition as which of the following?
A) Central cord syndrome
B) Spinal shock syndrome
