1|Page
SPINAL CORD INJURY NCLEX {QUESTIONS WITH
100% CORRECT ANSWERS} ()(VERIFIED BY
EXPERTS)
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
elevated blood pressure, may indicate fecal impaction. The other answers will not cause
autonomic dysreflexia.
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An unconscious patient receiving emergency care following an automobile crash accident has a
possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient's head will be secured with a belt or tape secured to the stretcher. - - ANS✔️--
Correct Answer: 1,2,5
Rationale: In the emergency setting, all patients who have sustained a trauma to the head or
spine, or are unconscious should be treated as though they have a spinal cord injury.
Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent
movement are all basic guidelines of emergency care. Placement on the ventilator and raising the
head of the bed will be considered after admittance to the hospital.
A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the
patient should not develop a full bladder because what emergency condition can occur if it is not
corrected quickly?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure - - ANS✔️--Correct Answer: 1
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Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury
(SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track
urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other
causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis,
autonomic shutdown, and autonomic failure are not terms used to describe common
complications of spinal injury associated with bladder distension.
Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team - - ANS✔️--Correct Answer: 1
Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults),
gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less
risk-taking behavior than young men.
The nurse understands that when the spinal cord is injured, ischemia results and edema occurs.
How should the nurse explain to the patient the reason that the extent of injury cannot be
determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury for two cord segments above and below the affected
level."
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3. "Neurons need time to regenerate so stating the injury early is not predictive of how the
patient progresses."
4. "Necrosis of gray and white matter does not occur until days after the injury." - - ANS✔️--
Correct Answer: 2
Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been
prolonged and the function of nerves passing through the injured area is lost. Because the edema
extends above and below the area affected, the extent of injury cannot be determined until after
the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the
ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and
complete paralysis of the lower part of the body. The nurse should use which medical term to
adequately describe this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia - - ANS✔️--Correct Answer: 4
Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete
paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body.
Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
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.
SPINAL CORD INJURY NCLEX {QUESTIONS WITH
100% CORRECT ANSWERS} ()(VERIFIED BY
EXPERTS)
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
elevated blood pressure, may indicate fecal impaction. The other answers will not cause
autonomic dysreflexia.
,2|Page
An unconscious patient receiving emergency care following an automobile crash accident has a
possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient's head will be secured with a belt or tape secured to the stretcher. - - ANS✔️--
Correct Answer: 1,2,5
Rationale: In the emergency setting, all patients who have sustained a trauma to the head or
spine, or are unconscious should be treated as though they have a spinal cord injury.
Immobilizing the neck, maintaining a supine position and securing the patient's head to prevent
movement are all basic guidelines of emergency care. Placement on the ventilator and raising the
head of the bed will be considered after admittance to the hospital.
A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes that the
patient should not develop a full bladder because what emergency condition can occur if it is not
corrected quickly?
1. autonomic dysreflexia
2. autonomic crisis
3. autonomic shutdown
4. autonomic failure - - ANS✔️--Correct Answer: 1
,3|Page
Rationale: Be attuned to the prevention of a distended bladder when caring for spinal cord injury
(SCI) patients in order to prevent this chain of events that lead to autonomic dysreflexia. Track
urinary output carefully. Routine use of bladder scanning can help prevent the occurrence. Other
causes of autonomic dysreflexia are impacted stool and skin pressure. Autonomic crisis,
autonomic shutdown, and autonomic failure are not terms used to describe common
complications of spinal injury associated with bladder distension.
Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team - - ANS✔️--Correct Answer: 1
Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults),
gender (higher incidence in males), and alcohol or drug abuse. Females tend to engage in less
risk-taking behavior than young men.
The nurse understands that when the spinal cord is injured, ischemia results and edema occurs.
How should the nurse explain to the patient the reason that the extent of injury cannot be
determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury for two cord segments above and below the affected
level."
, 4|Page
3. "Neurons need time to regenerate so stating the injury early is not predictive of how the
patient progresses."
4. "Necrosis of gray and white matter does not occur until days after the injury." - - ANS✔️--
Correct Answer: 2
Rationale: Within 24 hours necrosis of both gray and white matter begins if ischemia has been
prolonged and the function of nerves passing through the injured area is lost. Because the edema
extends above and below the area affected, the extent of injury cannot be determined until after
the edema is controlled. Neurons do not regenerate, and the edema is the factor that limits the
ability to predict extent of injury.
A patient with a spinal cord injury (SCI) has complete paralysis of the upper extremities and
complete paralysis of the lower part of the body. The nurse should use which medical term to
adequately describe this in documentation?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia - - ANS✔️--Correct Answer: 4
Rationale: Quadriplegia describes complete paralysis of the upper extremities and complete
paralysis of the lower part of the body. Hemiplegia describes paralysis on one side of the body.
Paresthesia does not indicate paralysis. Paraplegia is paralysis of the lower body.
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.
