CVA NCLEX real Actual EXAM
CVA NCLEX real Actual EXAM 1 Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU).
The nurse will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury. –
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
Correct Answer :Correct Answer(s): B
Rationale: The patient with a T1 injury can expect to retain full motor and sensory
function of the arms. Use of only the shoulders is associated with cervical spine
injury. Total loss of respiratory function occurs with injuries above the C4 level and
is permanent. Bradycardia is associated with injuries above the T6 level.
The health care provider orders administration of IV methylprednisolone (Solu-
Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at
the T10 level 3 hours ago. When evaluating the effectiveness of the medication the
nurse will assess
a. blood pressure and heart rate.
b. respiratory effort and O2 saturation.
c. motor and sensory function of the legs.
d. bowel sounds and abdominal distension. –
Correct Answer :Correct Answer(s): C
Rationale: The purpose of methylprednisolone administration is to help preserve
neurologic function; therefore, the nurse will assess this patient for lower-
extremity function. Sympathetic nervous system dysfunction occurs with injuries at
or above T6, so monitoring of BP and heart rate will not be useful in determining
the effectiveness of the medication. Respiratory and GI function will not be
impaired by a T10 injury, so assessments of these systems will not provide
information about whether the medication is effective.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic
reflex bladder. When the nurse develops a plan of care for this problem, which
nursing action will be most appropriate?
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding –
Correct Answer :Correct Answer(s): A
Rationale: Because the patient's bladder is spastic and will empty in response to
overstretching of the bladder wall, the most appropriate method is to avoid
incontinence by emptying the bladder at regular intervals through intermittent
catheterization. Assisting the patient to the toilet will not be helpful because the
bladder will not empty. The Credé method is more appropriate for a bladder that is
flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after
voiding will not resolve the patient's incontinence.
A patient with a history of a T2 spinal cord 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. Notify the patient's health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction. –
Correct Answer :Correct Answer(s): B
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
Rationale: 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 causing the symptoms, including hypertension.
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.
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An
appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces. –
Correct Answer :Correct Answer(s): D
Rationale: 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.
A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the
injury and becomes verbally abusive to the nurses and other staff. The patient
demands to be transferred to another hospital, where "they know what they are
doing." The best response by the nurse to the patient's behavior is to
a. ask for the patient's input into the plan for care.
b. clarify that abusive behavior will not be tolerated.
A+ TEST BANK 4
CVA NCLEX real Actual EXAM 1 Complete
Verified Questions And Correct Detailed
Answers with Rationales Graded A+
Guaranteed Pass
A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU).
The nurse will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury. –
A+ TEST BANK 1
, CVA NCLEX real Actual EXAM
Correct Answer :Correct Answer(s): B
Rationale: The patient with a T1 injury can expect to retain full motor and sensory
function of the arms. Use of only the shoulders is associated with cervical spine
injury. Total loss of respiratory function occurs with injuries above the C4 level and
is permanent. Bradycardia is associated with injuries above the T6 level.
The health care provider orders administration of IV methylprednisolone (Solu-
Medrol) for the first 24 hours to a patient who experienced a spinal cord injury at
the T10 level 3 hours ago. When evaluating the effectiveness of the medication the
nurse will assess
a. blood pressure and heart rate.
b. respiratory effort and O2 saturation.
c. motor and sensory function of the legs.
d. bowel sounds and abdominal distension. –
Correct Answer :Correct Answer(s): C
Rationale: The purpose of methylprednisolone administration is to help preserve
neurologic function; therefore, the nurse will assess this patient for lower-
extremity function. Sympathetic nervous system dysfunction occurs with injuries at
or above T6, so monitoring of BP and heart rate will not be useful in determining
the effectiveness of the medication. Respiratory and GI function will not be
impaired by a T10 injury, so assessments of these systems will not provide
information about whether the medication is effective.
A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic
reflex bladder. When the nurse develops a plan of care for this problem, which
nursing action will be most appropriate?
A+ TEST BANK 2
, CVA NCLEX real Actual EXAM
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding –
Correct Answer :Correct Answer(s): A
Rationale: Because the patient's bladder is spastic and will empty in response to
overstretching of the bladder wall, the most appropriate method is to avoid
incontinence by emptying the bladder at regular intervals through intermittent
catheterization. Assisting the patient to the toilet will not be helpful because the
bladder will not empty. The Credé method is more appropriate for a bladder that is
flaccid, such as occurs with a reflexic neurogenic bladder. Catheterization after
voiding will not resolve the patient's incontinence.
A patient with a history of a T2 spinal cord 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. Notify the patient's health care provider.
b. Check the blood pressure (BP).
c. Give the ordered antiemetic.
d. Assess for a fecal impaction. –
Correct Answer :Correct Answer(s): B
A+ TEST BANK 3
, CVA NCLEX real Actual EXAM
Rationale: 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 causing the symptoms, including hypertension.
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.
The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An
appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces. –
Correct Answer :Correct Answer(s): D
Rationale: 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.
A patient who sustained a T1 spinal cord injury a week ago refuses to discuss the
injury and becomes verbally abusive to the nurses and other staff. The patient
demands to be transferred to another hospital, where "they know what they are
doing." The best response by the nurse to the patient's behavior is to
a. ask for the patient's input into the plan for care.
b. clarify that abusive behavior will not be tolerated.
A+ TEST BANK 4
