NUR 213 Spinal Cord Injury
1. When a client is admitted to the emergency department with a possible spinal cord injury,
the nurse would monitor for which clinical manifestationsof spinal shock? Select all that
apply.
1. Bradycardia
2. Hypotension
3. Spastic paralysis
4. Urinary retention
5. Increased pulse pressure: 1. Bradycardia (due to vasodilation below level ofinjury)
2. Hypotension (loss of vascular tone below the injury)
4. Urinary retention (due to autonomic nervous system dysfunction)
2. Which problem is the nurse trying to prevent by encouraging a client with aspinal cord injury
to increase oral fluid intake?
1. Dehydration
2. Skin breakdown
3. Electrolyte imbalances
4. Urinary tract infections: 4. Urinary tract infections
High fluid intake limits urinary stasis and infection by diluting the urine and increasingurinary
output.
3. While caring for a client in traction, which action would the nurse delegateto a licensed
practical nurse (LPN)? Select all that apply.
1. Padding traction connections
2. Determining correct body alignment
3. Assessing complications associated with immobility
4. Teaching the client about range-of-motion (ROM) exercises
5. Assisting the client with passive and active range-of-motion exercises: 1.Padding traction
connections
5. Assisting the client with passive and active range-of-motion exercises
, 4. Which intervention would the nurse perform first for a client with a spinalcord injury who is
experiencing autonomic dysreflexia?
1. Assess for the cause.
2. Place the client in sitting position.
3. Check the client for fecal impaction.
4. Give an alpha blocker prophylactically.: 2. Place the client in sitting position
Clients with autonomic dysreflexia would immediately be placed in a sitting position because
the condition may cause involuntary nervous system reaction and danger- ous spikes in blood
pressure.
5. A client with a cervical injury reports the sudden onset of a severe headacheand nasal
congestion. For which clinical manifestations would the nurse assess?
1. Suprapubic distention
2. Increased spinal reflexes
3. Adventitious breath sounds
4. Imminent development of shock: 1. Suprapubic distention
Suprapubic distention is a symptom of autonomic dysreflexia, which is commonlyprecipitated
by a distended bladder. Blood pressure increases suddenly with AE causing the severe
headache and nasal congestion.
6. In which position would the nurse place a client with a spinal cord injuryexperiencing
autonomic dysreflexia?
1. High Fowler
2. Left side-lying
3. Right side-lying
4. Flat on the back: 1. High Fowler
A client experiencing AE would immediately be placed sitting up to lower bloodpressure.
7. Which nursing action would have the highest priority when the nurse is moving a client with
a neck and spinal cord injury during the assessmentprocess?
1. Removing the cervical spine collar
1. When a client is admitted to the emergency department with a possible spinal cord injury,
the nurse would monitor for which clinical manifestationsof spinal shock? Select all that
apply.
1. Bradycardia
2. Hypotension
3. Spastic paralysis
4. Urinary retention
5. Increased pulse pressure: 1. Bradycardia (due to vasodilation below level ofinjury)
2. Hypotension (loss of vascular tone below the injury)
4. Urinary retention (due to autonomic nervous system dysfunction)
2. Which problem is the nurse trying to prevent by encouraging a client with aspinal cord injury
to increase oral fluid intake?
1. Dehydration
2. Skin breakdown
3. Electrolyte imbalances
4. Urinary tract infections: 4. Urinary tract infections
High fluid intake limits urinary stasis and infection by diluting the urine and increasingurinary
output.
3. While caring for a client in traction, which action would the nurse delegateto a licensed
practical nurse (LPN)? Select all that apply.
1. Padding traction connections
2. Determining correct body alignment
3. Assessing complications associated with immobility
4. Teaching the client about range-of-motion (ROM) exercises
5. Assisting the client with passive and active range-of-motion exercises: 1.Padding traction
connections
5. Assisting the client with passive and active range-of-motion exercises
, 4. Which intervention would the nurse perform first for a client with a spinalcord injury who is
experiencing autonomic dysreflexia?
1. Assess for the cause.
2. Place the client in sitting position.
3. Check the client for fecal impaction.
4. Give an alpha blocker prophylactically.: 2. Place the client in sitting position
Clients with autonomic dysreflexia would immediately be placed in a sitting position because
the condition may cause involuntary nervous system reaction and danger- ous spikes in blood
pressure.
5. A client with a cervical injury reports the sudden onset of a severe headacheand nasal
congestion. For which clinical manifestations would the nurse assess?
1. Suprapubic distention
2. Increased spinal reflexes
3. Adventitious breath sounds
4. Imminent development of shock: 1. Suprapubic distention
Suprapubic distention is a symptom of autonomic dysreflexia, which is commonlyprecipitated
by a distended bladder. Blood pressure increases suddenly with AE causing the severe
headache and nasal congestion.
6. In which position would the nurse place a client with a spinal cord injuryexperiencing
autonomic dysreflexia?
1. High Fowler
2. Left side-lying
3. Right side-lying
4. Flat on the back: 1. High Fowler
A client experiencing AE would immediately be placed sitting up to lower bloodpressure.
7. Which nursing action would have the highest priority when the nurse is moving a client with
a neck and spinal cord injury during the assessmentprocess?
1. Removing the cervical spine collar
