Spinal Cord Injury NCLEX Exam Test with Verified Answers
1. The nurse is caring for a patient ad- Correct Answer(s): B
mitted with a spinal cord injury follow- About 50% of people with acute
ing a motor vehicle accident. The pa- spinal cord injury experience a tem-
tient exhibits a complete loss of motor, porary loss of reflexes, sensation,
sensory, and reflex activity below the and motor activity that is known
injury level. The nurse recognizes this as spinal shock. Central cord syn-
condition as which of the following? drome is manifested by motor and
A) Central cord syndrome sensory loss greater in the upper
B) Spinal shock syndrome extremities than the lower extremi-
C) Anterior cord syndrome ties. Anterior cord syndrome results
D) Brown-Séquard in motor and sensory loss but not
reflexes. Brown-Séquard syndrome
is characterized by ipsilateral loss
of motor function and contralateral
loss of sensory function.
2. Which of the following clinical man- Correct Answer(s): A
ifestations would the nurse interpret Neurogenic shock is due to the loss
as representing neurogenic shock in a of vasomotor tone caused by injury
patient with acute spinal cord injury? and is characterized by hypoten-
A) Bradycardia sion and bradycardia. Loss of sym-
B) Hypertension pathetic innervation causes periph-
C) Neurogenic spasticity eral vasodilation, venous pooling,
D) Bounding pedal pulses and a decreased cardiac output.
3. The nurse is caring for a patient admit- Correct Answer(s): D
ted 1 week ago with an acute spinal Autonomic dysreflexia is related to
cord injury. Which of the following reflex stimulation of the sympathet-
assessment findings would alert the ic nervous system reflected by hy-
nurse to the presence of autonomic pertension, bradycardia, throbbing
dysreflexia? headache, and diaphoresis.
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache
4. When planning care for a patient with Correct Answer(s): D
a C5 spinal cord injury, which nursing Maintaining a patent airway is the
diagnosis is the highest priority? most important goal for a patient
, Spinal Cord Injury NCLEX Exam Test with Verified Answers
A) Risk for impairment of tissue in- with a high cervical fracture. Al-
tegrity caused by paralysis though all of these are appropri-
B) Altered patterns of urinary elimina- ate nursing diagnoses for a patient
tion caused by quadriplegia with a spinal cord injury, respiratory
C) Altered family and individual cop- needs are always the highest prior-
ing caused by the extent of trauma ity. Remember the ABCs.
D) Ineffective airway clearance caused
by high cervical spinal cord injury
5. Which of the following signs and Correct Answer(s): A
symptoms in a patient with a T4 spinal Among the manifestations of auto-
cord injury should alert the nurse to nomic dysreflexia are hypertension
the possibility of autonomic dysreflex- (up to 300 mm Hg systolic) and
ia? a throbbing headache. Respiratory
A) Headache and rising blood pres- manifestations, decreased level of
sure consciousness, and gastrointesti-
B) Irregular respirations and short- nal manifestations are not charac-
ness of breath teristic.
C) Decreased level of consciousness
or hallucinations
D) Abdominal distention and absence
of bowel sounds
6. Which of the following interventions Correct Answer(s): A
should the nurse perform in the acute Because the most common cause
care of a patient with autonomic dys- of autonomic dysreflexia is blad-
reflexia? der irritation, immediate catheter-
A) Urinary catheterization ization to relieve bladder disten-
B) Administration of benzodiazepines tion may be necessary. The patient
C) Suctioning of the patient's upper should be positioned upright. Ben-
airway zodiazepines are contraindicated
D) Placement of the patient in the Tren- and suctioning is likely unneces-
delenburg position sary.
7. Nurse is assessing a patient who has Correct Answer (s): a, c, d, e
a spinal cord injury?Which should the the assessment to determine the
nurse include in the nervous system level of spinal cord injury includes
assessment to determine the extent of analyzing the -vital sign, plantar re-
the patient's injury? flexes, bilatereal hand grasp, de-
1. The nurse is caring for a patient ad- Correct Answer(s): B
mitted with a spinal cord injury follow- About 50% of people with acute
ing a motor vehicle accident. The pa- spinal cord injury experience a tem-
tient exhibits a complete loss of motor, porary loss of reflexes, sensation,
sensory, and reflex activity below the and motor activity that is known
injury level. The nurse recognizes this as spinal shock. Central cord syn-
condition as which of the following? drome is manifested by motor and
A) Central cord syndrome sensory loss greater in the upper
B) Spinal shock syndrome extremities than the lower extremi-
C) Anterior cord syndrome ties. Anterior cord syndrome results
D) Brown-Séquard in motor and sensory loss but not
reflexes. Brown-Séquard syndrome
is characterized by ipsilateral loss
of motor function and contralateral
loss of sensory function.
2. Which of the following clinical man- Correct Answer(s): A
ifestations would the nurse interpret Neurogenic shock is due to the loss
as representing neurogenic shock in a of vasomotor tone caused by injury
patient with acute spinal cord injury? and is characterized by hypoten-
A) Bradycardia sion and bradycardia. Loss of sym-
B) Hypertension pathetic innervation causes periph-
C) Neurogenic spasticity eral vasodilation, venous pooling,
D) Bounding pedal pulses and a decreased cardiac output.
3. The nurse is caring for a patient admit- Correct Answer(s): D
ted 1 week ago with an acute spinal Autonomic dysreflexia is related to
cord injury. Which of the following reflex stimulation of the sympathet-
assessment findings would alert the ic nervous system reflected by hy-
nurse to the presence of autonomic pertension, bradycardia, throbbing
dysreflexia? headache, and diaphoresis.
A) Tachycardia
B) Hypotension
C) Hot, dry skin
D) Throbbing headache
4. When planning care for a patient with Correct Answer(s): D
a C5 spinal cord injury, which nursing Maintaining a patent airway is the
diagnosis is the highest priority? most important goal for a patient
, Spinal Cord Injury NCLEX Exam Test with Verified Answers
A) Risk for impairment of tissue in- with a high cervical fracture. Al-
tegrity caused by paralysis though all of these are appropri-
B) Altered patterns of urinary elimina- ate nursing diagnoses for a patient
tion caused by quadriplegia with a spinal cord injury, respiratory
C) Altered family and individual cop- needs are always the highest prior-
ing caused by the extent of trauma ity. Remember the ABCs.
D) Ineffective airway clearance caused
by high cervical spinal cord injury
5. Which of the following signs and Correct Answer(s): A
symptoms in a patient with a T4 spinal Among the manifestations of auto-
cord injury should alert the nurse to nomic dysreflexia are hypertension
the possibility of autonomic dysreflex- (up to 300 mm Hg systolic) and
ia? a throbbing headache. Respiratory
A) Headache and rising blood pres- manifestations, decreased level of
sure consciousness, and gastrointesti-
B) Irregular respirations and short- nal manifestations are not charac-
ness of breath teristic.
C) Decreased level of consciousness
or hallucinations
D) Abdominal distention and absence
of bowel sounds
6. Which of the following interventions Correct Answer(s): A
should the nurse perform in the acute Because the most common cause
care of a patient with autonomic dys- of autonomic dysreflexia is blad-
reflexia? der irritation, immediate catheter-
A) Urinary catheterization ization to relieve bladder disten-
B) Administration of benzodiazepines tion may be necessary. The patient
C) Suctioning of the patient's upper should be positioned upright. Ben-
airway zodiazepines are contraindicated
D) Placement of the patient in the Tren- and suctioning is likely unneces-
delenburg position sary.
7. Nurse is assessing a patient who has Correct Answer (s): a, c, d, e
a spinal cord injury?Which should the the assessment to determine the
nurse include in the nervous system level of spinal cord injury includes
assessment to determine the extent of analyzing the -vital sign, plantar re-
the patient's injury? flexes, bilatereal hand grasp, de-
