NUR 254- Unit 2.3 EXAM QUESTIONS WITH
CORRECTLY VERIFIED ANSWERS
how would the nurse "grade" muscle strength for a patient who was not able to move to some
resistance but not full resistance? - Correct Answers -4 (out of 5)
a patient paralyzed from the neck down is said to have what? - Correct Answers -quadraplegia
a patient with weakness from the waist down would be documented as what? - Correct
Answers -paraparesis
a patient with spinal cord injury <8 hours ago, present with hypotension, bradycardia, and
absent reflexes and flaccid paralysis below the level of injury. what complication is this
indicative of? - Correct Answers -spinal shock
the nurse would anticipate which electrolyte imbalance related to immobility for a patient with
a complete cord injury at T5? - Correct Answers -hypercalcemia
at what level will a patient with complete spinal cord injury be ventilator dependent? - Correct
Answers -C4 (above C5)
aside from ensuring ABCs, what should the priority intervention be for a patient with suspected
spinal cord injury? - Correct Answers -immobilization
a patient is at risk for autonomic dysreflexia. what are three things that could stimulate AD? -
Correct Answers -full bladder/bowel, skin irritation (tight clothing, SCDS, etc.), pressure areas
the patient with acute spinal cord injury is receiving high dose methylprednisolone. what is the
purpose for this medication? - Correct Answers -decrease inflammation and decrease secondary
injury to the spinal cord
, at what level of SCI will a patient be ventilator dependent? - Correct Answers -C4
above which level of injury would a patient be at high risk for neurogenic shock and AD? -
Correct Answers -T6
a patient is unable to move or feel from the waist down. what would this be documented as? -
Correct Answers -paraplegia
a patient should be suspected as having a SCI and should be immobilized until ruled out for
what reasons? - Correct Answers -head trauma, GSW near spinal column, fall, MVC
when explaining spinal shock to a family member what should the nurse say? - Correct Answers
-it is like a concussion of the spinal cord and will resolve over time with increasing reflexes and
then hyperactive reflexes
a nurse stops to help after witnessing an accident involving adolescent riding a motorcycle,
hitting a tree and being thrown 30 feet into a field. the adolescent reports that he is unable to
move his legs. while waiting for EMS, what should the nurse do? - Correct Answers -leave the
adolescent as he is, staying with him
the nurse auscultates closely for bowel sounds when assessing a patient with SCI because? -
Correct Answers -the complication of paralytic ileus
the family of a patient with a fresh spinal cord injury asks what the methylprednisolone infusion
is for. what should the nurse say? - Correct Answers -it is to decrease inflammation and
decrease further injury to the spinal cord secondary to inflammatory response after the initial
injury
CORRECTLY VERIFIED ANSWERS
how would the nurse "grade" muscle strength for a patient who was not able to move to some
resistance but not full resistance? - Correct Answers -4 (out of 5)
a patient paralyzed from the neck down is said to have what? - Correct Answers -quadraplegia
a patient with weakness from the waist down would be documented as what? - Correct
Answers -paraparesis
a patient with spinal cord injury <8 hours ago, present with hypotension, bradycardia, and
absent reflexes and flaccid paralysis below the level of injury. what complication is this
indicative of? - Correct Answers -spinal shock
the nurse would anticipate which electrolyte imbalance related to immobility for a patient with
a complete cord injury at T5? - Correct Answers -hypercalcemia
at what level will a patient with complete spinal cord injury be ventilator dependent? - Correct
Answers -C4 (above C5)
aside from ensuring ABCs, what should the priority intervention be for a patient with suspected
spinal cord injury? - Correct Answers -immobilization
a patient is at risk for autonomic dysreflexia. what are three things that could stimulate AD? -
Correct Answers -full bladder/bowel, skin irritation (tight clothing, SCDS, etc.), pressure areas
the patient with acute spinal cord injury is receiving high dose methylprednisolone. what is the
purpose for this medication? - Correct Answers -decrease inflammation and decrease secondary
injury to the spinal cord
, at what level of SCI will a patient be ventilator dependent? - Correct Answers -C4
above which level of injury would a patient be at high risk for neurogenic shock and AD? -
Correct Answers -T6
a patient is unable to move or feel from the waist down. what would this be documented as? -
Correct Answers -paraplegia
a patient should be suspected as having a SCI and should be immobilized until ruled out for
what reasons? - Correct Answers -head trauma, GSW near spinal column, fall, MVC
when explaining spinal shock to a family member what should the nurse say? - Correct Answers
-it is like a concussion of the spinal cord and will resolve over time with increasing reflexes and
then hyperactive reflexes
a nurse stops to help after witnessing an accident involving adolescent riding a motorcycle,
hitting a tree and being thrown 30 feet into a field. the adolescent reports that he is unable to
move his legs. while waiting for EMS, what should the nurse do? - Correct Answers -leave the
adolescent as he is, staying with him
the nurse auscultates closely for bowel sounds when assessing a patient with SCI because? -
Correct Answers -the complication of paralytic ileus
the family of a patient with a fresh spinal cord injury asks what the methylprednisolone infusion
is for. what should the nurse say? - Correct Answers -it is to decrease inflammation and
decrease further injury to the spinal cord secondary to inflammatory response after the initial
injury
