Spinal Cord Injury NCLEX QUESTIONS AND ANSWERS 100%
RATED CORRECT WITH 100% SURE PASS /GRADED A+
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?
1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
Ans: Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a
life-threatening situation that will require immediate intervention or the patient will die. The
most common cause is an overextended bladder or bowel. Symptoms include hypertension,
headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing
environment is fine, though not what the patient needs in this case. The nurse should recognize
this as an emergency and proceed accordingly. Once the assessment has been completed, the
findings will need to be communicated to the healthcare provider.
Quiz A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore."
Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
2. Call the healthcare provider and get an order for radiologic evaluation.
,3. Prepare the patient for surgery, as her condition is worsening.
4. Explain to the patient that this could be a common, temporary problem.
Ans: Correct Answer: 4
Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience.
It is characterized by a temporary loss of reflex function below level of injury, and includes the
following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the
injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the
injury level. In this case, the nurse should explain to the patient what is happening.
Quiz The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse
realizes that some nursing actions are contraindicated with IICP. Which nursing action should
be avoided?
1. Reposition the patient every two hours.
2. Position the patient with the head elevated 30 degrees.
3. Suction the airway every two hours per standing orders.
4. Provide continuous oxygen as ordered.
Ans: Correct Answer: 3
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be
done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort
by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent
(or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.
Quiz A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction.
Which of the following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
, 2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion
Ans: Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial applying of the traction device. The
weights on the traction device must not be changed without the order of a healthcare provider.
When caring for a patient in traction, the nurse is responsible for assessment and care of the
skin due to the increased risk of skin breakdown. The patient in traction is likely to experience
pain and the nurse is responsible for assessing this pain and administering the appropriate
analgesic as ordered. Passive range of motion helps prevent contractures; this is often
performed by a physical therapist or a nurse.
Quiz A patient has manifestations of autonomic dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction
Ans: Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder
to become full, triggering massive vasoconstriction below the injury site, producing the
manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained
RATED CORRECT WITH 100% SURE PASS /GRADED A+
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?
1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
Ans: Correct Answer: 2
Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or higher, and is a
life-threatening situation that will require immediate intervention or the patient will die. The
most common cause is an overextended bladder or bowel. Symptoms include hypertension,
headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea. A calm, soothing
environment is fine, though not what the patient needs in this case. The nurse should recognize
this as an emergency and proceed accordingly. Once the assessment has been completed, the
findings will need to be communicated to the healthcare provider.
Quiz A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs anymore."
Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
2. Call the healthcare provider and get an order for radiologic evaluation.
,3. Prepare the patient for surgery, as her condition is worsening.
4. Explain to the patient that this could be a common, temporary problem.
Ans: Correct Answer: 4
Rationale: Spinal shock is a condition almost half the people with acute spinal injury experience.
It is characterized by a temporary loss of reflex function below level of injury, and includes the
following symptomatology: flaccid paralysis of skeletal muscles, loss of sensation below the
injury, and possibly bowel and bladder dysfunction and loss of ability to perspire below the
injury level. In this case, the nurse should explain to the patient what is happening.
Quiz The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse
realizes that some nursing actions are contraindicated with IICP. Which nursing action should
be avoided?
1. Reposition the patient every two hours.
2. Position the patient with the head elevated 30 degrees.
3. Suction the airway every two hours per standing orders.
4. Provide continuous oxygen as ordered.
Ans: Correct Answer: 3
Rationale: Suctioning further increases intracranial pressure; therefore, suctioning should be
done to maintain a patent airway but not as a matter of routine. Maintaining patient comfort
by frequent repositioning as well as keeping the head elevated 30 degrees will help to prevent
(or even reduce) IICP. Keeping the patient properly oxygenated may also help to control ICP.
Quiz A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction.
Which of the following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed
, 2. assessing the patient's skin integrity
3. applying the traction upon admission
4. administering pain medication
5. providing passive range of motion
Ans: Correct Answer: 2,4,5
Rationale: The healthcare provider is responsible for initial applying of the traction device. The
weights on the traction device must not be changed without the order of a healthcare provider.
When caring for a patient in traction, the nurse is responsible for assessment and care of the
skin due to the increased risk of skin breakdown. The patient in traction is likely to experience
pain and the nurse is responsible for assessing this pain and administering the appropriate
analgesic as ordered. Passive range of motion helps prevent contractures; this is often
performed by a physical therapist or a nurse.
Quiz A patient has manifestations of autonomic dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension
2. kinked catheter tubing
3. respiratory wheezes and stridor
4. diarrhea
5. fecal impaction
Ans: Correct Answer: 2,5
Rationale: Autonomic dysreflexia can be caused by kinked catheter tubing allowing the bladder
to become full, triggering massive vasoconstriction below the injury site, producing the
manifestations of this process. Acute symptoms of autonomic dysreflexia, including a sustained
