NMNEC 2310 HEALTH AND ILLNESS CONCEPTS II -
EXAM 3 PRACTICE QUESTIONS AND CORRECT
ANSWERS
You are caring for a patient admitted 1 week earlier with an acute spinal cord injury.
Which assessment finding alerts you to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - Answers - D. Throbbing headache
Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system,
which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
Which clinical manifestation do you interpret as representing neurogenic shock in a
patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - Answers - A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by injury and is
characterized by hypotension and bradycardia. Loss of sympathetic innervation causes
peripheral vasodilation, venous pooling, and a decreased cardiac output.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is
the highest priority?
A. Impaired tissue integrity due to paralysis
B. Impaired urinary elimination due to quadriplegia
C. Ineffective coping due to the extent of trauma
D. Ineffective airway clearance due to high cervical spinal cord injury - Answers - D.
Ineffective airway clearance due to high cervical spinal cord injury
Maintaining a patent airway is the most important goal for a patient with a high cervical
fracture. Although all of these options are appropriate nursing diagnoses for a patient
with a spinal cord injury, respiratory needs are always the highest priority. Remember
the ABCs.
,Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to
the possibility of 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 - Answers - A. Headache and
rising blood pressure
Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg
systolic) and throbbing headache. Respiratory manifestations, decreased level of
consciousness, and gastrointestinal manifestations are not characteristic.
What are the goals of rehabilitation for the patient with an injury at the C6 level (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 wheel chair - Answers - B. Feed self with hand devices
C. Drive an electric wheelchair
D. Assist with transfer activities
E. Drive adapted van from wheel chair
Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability
to assist with transfer and perform some self-care; feed self with hand devices; push
wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent
computer use with adaptive equipment; and needing attendant care only for 6 hours per
day.
A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have
the flu because he has a bad headache and nausea. What is your initial action?
A. Call the physician.
B. Check the patient's temperature.
C. Take the patient's blood pressure.
D. Elevate the head of the bed to 90 degrees. - Answers - C. Take the patient's blood
pressure.
Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated
by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm
Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion,
bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of
the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and
, nausea. It is important to measure blood pressure when a patient with a spinal cord
injury complains of a headache.
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord
injury, an appropriate patient goal is that the patient will be able to
A. transfer independently to a wheelchair.
B. drive a car with powered hand controls.
C. turn and reposition independently when in bed.
D. push a manual wheelchair on flat, smooth surfaces. - Answers - D. push a manual
wheelchair on flat, smooth surfaces
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat,
smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will
not be able to grasp a wheelchair during transfer, drive a car with powered hand
controls, or turn independently in bed.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord
injury, which nursing action has the highest priority?
A. Assessment of respiratory rate and depth
B. Continuous cardiac monitoring for bradycardia
C. Application of pneumatic compression devices to both legs
D. Administration of methylprednisolone (Solu-Medrol) infusion - Answers - A.
Assessment of respiratory rate and depth
Edema around the area of injury may lead to damage above the C4 level, so the highest
priority is assessment of the patient's respiratory function. The other actions also are
appropriate but are not as important as assessment of respiratory effort
.A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My
head is throbbing, and I feel sick to my stomach." Which action should the nurse take
first?
A. Assess for a fecal impaction.
B. Give the prescribed antiemetic.
C. Check the blood pressure (BP).
D. Notify the health care provider. - Answers - C. Check the blood pressure (BP).
The BP should be assessed immediately in a patient with an injury at the T6 level or
higher who complains of a headache to determine whether autonomic dysreflexia is
occurring. Notification of the patient's health care provider is appropriate after the BP is
obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is
ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but
this should be done after checking the BP and lidocaine jelly should be used to prevent
further increases in the BP.
EXAM 3 PRACTICE QUESTIONS AND CORRECT
ANSWERS
You are caring for a patient admitted 1 week earlier with an acute spinal cord injury.
Which assessment finding alerts you to the presence of autonomic dysreflexia?
A. Tachycardia
B. Hypotension
C. Hot, dry skin
D. Throbbing headache - Answers - D. Throbbing headache
Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system,
which is reflected by hypertension, bradycardia, throbbing headache, and diaphoresis.
Which clinical manifestation do you interpret as representing neurogenic shock in a
patient with acute spinal cord injury?
A. Bradycardia
B. Hypertension
C. Neurogenic spasticity
D. Bounding pedal pulses - Answers - A. Bradycardia
Neurogenic shock results from loss of vasomotor tone caused by injury and is
characterized by hypotension and bradycardia. Loss of sympathetic innervation causes
peripheral vasodilation, venous pooling, and a decreased cardiac output.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is
the highest priority?
A. Impaired tissue integrity due to paralysis
B. Impaired urinary elimination due to quadriplegia
C. Ineffective coping due to the extent of trauma
D. Ineffective airway clearance due to high cervical spinal cord injury - Answers - D.
Ineffective airway clearance due to high cervical spinal cord injury
Maintaining a patent airway is the most important goal for a patient with a high cervical
fracture. Although all of these options are appropriate nursing diagnoses for a patient
with a spinal cord injury, respiratory needs are always the highest priority. Remember
the ABCs.
,Which signs and symptoms in a patient with a T4 spinal cord injury should alert you to
the possibility of 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 - Answers - A. Headache and
rising blood pressure
Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg
systolic) and throbbing headache. Respiratory manifestations, decreased level of
consciousness, and gastrointestinal manifestations are not characteristic.
What are the goals of rehabilitation for the patient with an injury at the C6 level (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 wheel chair - Answers - B. Feed self with hand devices
C. Drive an electric wheelchair
D. Assist with transfer activities
E. Drive adapted van from wheel chair
Rehabilitation goals for a patient with a spinal cord injury at the C6 level include ability
to assist with transfer and perform some self-care; feed self with hand devices; push
wheelchair on smooth, flat surface; drive adapted van from wheelchair; independent
computer use with adaptive equipment; and needing attendant care only for 6 hours per
day.
A patient with a C7 spinal cord injury undergoing rehabilitation tells you he must have
the flu because he has a bad headache and nausea. What is your initial action?
A. Call the physician.
B. Check the patient's temperature.
C. Take the patient's blood pressure.
D. Elevate the head of the bed to 90 degrees. - Answers - C. Take the patient's blood
pressure.
Autonomic dysreflexia is a massive, uncompensated cardiovascular reaction mediated
by the sympathetic nervous system. Manifestations include hypertension (up to 300 mm
Hg systolic), throbbing headache, marked diaphoresis above the level of the lesion,
bradycardia (30 to 40 beats/minute), piloerection, flushing of the skin above the level of
the lesion, blurred vision or spots in the visual fields, nasal congestion, anxiety, and
, nausea. It is important to measure blood pressure when a patient with a spinal cord
injury complains of a headache.
When the nurse is developing a rehabilitation plan for a patient with a C6 spinal cord
injury, an appropriate patient goal is that the patient will be able to
A. transfer independently to a wheelchair.
B. drive a car with powered hand controls.
C. turn and reposition independently when in bed.
D. push a manual wheelchair on flat, smooth surfaces. - Answers - D. push a manual
wheelchair on flat, smooth surfaces
The patient with a C6 injury will be able to use the hands to push a wheelchair on flat,
smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will
not be able to grasp a wheelchair during transfer, drive a car with powered hand
controls, or turn independently in bed.
When caring for a patient who was admitted 24 hours previously with a C5 spinal cord
injury, which nursing action has the highest priority?
A. Assessment of respiratory rate and depth
B. Continuous cardiac monitoring for bradycardia
C. Application of pneumatic compression devices to both legs
D. Administration of methylprednisolone (Solu-Medrol) infusion - Answers - A.
Assessment of respiratory rate and depth
Edema around the area of injury may lead to damage above the C4 level, so the highest
priority is assessment of the patient's respiratory function. The other actions also are
appropriate but are not as important as assessment of respiratory effort
.A patient with a history of a T2 spinal cord injury tells the nurse, "I feel awful today. My
head is throbbing, and I feel sick to my stomach." Which action should the nurse take
first?
A. Assess for a fecal impaction.
B. Give the prescribed antiemetic.
C. Check the blood pressure (BP).
D. Notify the health care provider. - Answers - C. Check the blood pressure (BP).
The BP should be assessed immediately in a patient with an injury at the T6 level or
higher who complains of a headache to determine whether autonomic dysreflexia is
occurring. Notification of the patient's health care provider is appropriate after the BP is
obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is
ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but
this should be done after checking the BP and lidocaine jelly should be used to prevent
further increases in the BP.
