A patient who is being treated in the hospital for a spinal cord injury is
advocating for the removal of his urinary catheter, stating that he wants to
try to resume normal elimination. What principle should guide the care
team's decision regarding this intervention?
A) Urinary retention can have serious consequences in patients with SCIs.
B) Urinary function is permanently lost following an SCI.
C) Urinary catheters should not remain in place for more than 7 days.
D) Overuse of urinary catheters can exacerbate nerve damage.
Ans: A
Feedback:
Bladder distention, a major cause of autonomic dysreflexia, can also cause
trauma. For this reason, removal of a urinary catheter must be considered
with caution. Extended use of urinary catheterization is often necessary
following SCI. The effect of a spinal cord lesion on urinary function depends
on the level of the injury. Catheter use does not cause nerve damage,
although it is a major risk factor for UTIs.
`•°
A patient with spinal cord injury is ready to be discharged home. A family
member asks the nurse to review potential complications one more time.
What are the potential complications that should be monitored for in this
patient? Select all that apply.
,A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT
D) Salt-wasting syndrome
E) Increased ICP
Ans: A, B, C
Feedback:
For a spinal cord-injured patient, based on the assessment data, potential
complications that may develop include DVT, orthostatic hypotension, and
autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not
typical complications following the immediate recovery period.
`•°
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity.
How can the nurse best prevent this complication of an SCI?
A) Position the patient in a high Fowler's position when in bed.
,B) Support the knees with a pillow when the patient is in bed.
C) Perform passive ROM exercises as ordered.
D) Administer NSAIDs as ordered.
Ans: C
Feedback:
Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs
are not used for this purpose. Pillows and sitting upright do not directly
address the patient’s risk of muscle spasticity.
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When
writing the plan of care for this patient, which of the following nursing
diagnoses would the nurse prioritize in the immediate care of this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal
muscles
D) Urinary retention related to inability to void spontaneously
Ans: C
, Feedback:
A nursing diagnosis related to breathing pattern would be the priority for this
patient. A C4 spinal cord injury will require ventilatory support, due to the
diaphragm and intercostals being affected. The other nursing diagnoses
would be used in the care plan, but not designated as a higher priority than
ineffective breathing patterns.
1. A patient with possible bacterial meningitis is admitted to the ICU. What
assessment finding would the nurse expect for a patient with this diagnosis?
A) Pain upon ankle dorsiflexion of the foot
B) Neck flexion produces flexion of knees and hips
C) Inability to stand with eyes closed and arms extended without swaying
D) Numbness and tingling in the lower extremities
Ans: B
advocating for the removal of his urinary catheter, stating that he wants to
try to resume normal elimination. What principle should guide the care
team's decision regarding this intervention?
A) Urinary retention can have serious consequences in patients with SCIs.
B) Urinary function is permanently lost following an SCI.
C) Urinary catheters should not remain in place for more than 7 days.
D) Overuse of urinary catheters can exacerbate nerve damage.
Ans: A
Feedback:
Bladder distention, a major cause of autonomic dysreflexia, can also cause
trauma. For this reason, removal of a urinary catheter must be considered
with caution. Extended use of urinary catheterization is often necessary
following SCI. The effect of a spinal cord lesion on urinary function depends
on the level of the injury. Catheter use does not cause nerve damage,
although it is a major risk factor for UTIs.
`•°
A patient with spinal cord injury is ready to be discharged home. A family
member asks the nurse to review potential complications one more time.
What are the potential complications that should be monitored for in this
patient? Select all that apply.
,A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT
D) Salt-wasting syndrome
E) Increased ICP
Ans: A, B, C
Feedback:
For a spinal cord-injured patient, based on the assessment data, potential
complications that may develop include DVT, orthostatic hypotension, and
autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not
typical complications following the immediate recovery period.
`•°
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity.
How can the nurse best prevent this complication of an SCI?
A) Position the patient in a high Fowler's position when in bed.
,B) Support the knees with a pillow when the patient is in bed.
C) Perform passive ROM exercises as ordered.
D) Administer NSAIDs as ordered.
Ans: C
Feedback:
Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs
are not used for this purpose. Pillows and sitting upright do not directly
address the patient’s risk of muscle spasticity.
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When
writing the plan of care for this patient, which of the following nursing
diagnoses would the nurse prioritize in the immediate care of this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal
muscles
D) Urinary retention related to inability to void spontaneously
Ans: C
, Feedback:
A nursing diagnosis related to breathing pattern would be the priority for this
patient. A C4 spinal cord injury will require ventilatory support, due to the
diaphragm and intercostals being affected. The other nursing diagnoses
would be used in the care plan, but not designated as a higher priority than
ineffective breathing patterns.
1. A patient with possible bacterial meningitis is admitted to the ICU. What
assessment finding would the nurse expect for a patient with this diagnosis?
A) Pain upon ankle dorsiflexion of the foot
B) Neck flexion produces flexion of knees and hips
C) Inability to stand with eyes closed and arms extended without swaying
D) Numbness and tingling in the lower extremities
Ans: B
