Chapter 29: Spinal Cord Injury
Linton: Introduction to Medical-Surgical Nursing, 6th Edition
MULTIPLE CHOICE
1. A nurse explains that the spinal cord extends from the brainstem to the level of which
vertebra?
a.
Last thoracic
b.
Second lumbar
c.
First sacral
d.
Coccygeal
2. On admission to the emergency department, a patient with a C5 compression fracture can
move only his head and has flaccid paralysis of all extremities. The distraught family asks if
the paralysis is permanent. What is the best response by the nurse?
a.
“Yes. In all likelihood, the paralysis is probably permanent.”
b.
“No. Significant recovery of function should occur in a few days.”
c.
“It is too early to tell. When the spinal shock subsides, we will know more.”
d.
“You should talk to your physician about things of that nature.”
3. Which assessment would indicate the resolution of spinal shock?
a.
Extension and rigidity in affected limbs
b.
Spastic involuntary movements in affected limbs
c.
Tingling and burning in affected limbs
d.
Voluntary purposeful movements of affected limbs
4. Which assessment leads the emergency department nurse to suspect that a patient’s spinal
cord injury (SCI) is below C4?
a.
Voluntary eye movement
b.
Ability to blink the eyelids
c.
Unlabored respiration
d.
Ability to make a facial grimace
5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot against the
resistance of the nurse’s hand. The patient is unable to perform this action. Where does this
assessment confirm that cord damage has occurred?
a.
C4 to C5
b.
L2 to L4
c.
L5
d.
S1
6. What technique should the nurse implement to move the impaired legs of a patient with an
SCI to avoid stimulation muscle spasm?
a.
Firmly grasping the calf muscle and the thigh muscle
b.
Manipulating the limb by supporting the knee and ankle joints
c.
Holding the foot upright and slowly dragging the limb into position
d.
Requesting assistance to support the calf and thigh
7. When recording the findings of muscle strength, a nurse records a 2 for the right arm. How
should his score be interpreted?
a.
Weak contraction
b.
Muscle movement when supported
c.
Active muscle movement without support
d.
Full, active range-of-motion exercises against resistance
8. Which technique of opening the airway in the newly admitted patient with an SCI is the most
appropriate?
a.
Chin lift
b.
Head tilt
c.
Jaw thrust
d.
Neck flexion
9. Brown-Séquard syndrome results in which neurologic deficit?
a.
Bilateral loss of pain sensation below the level of injury
b.
Bilateral loss of temperature and motor function below the level of injury
c.
Motor and sensory loss in the upper extremities only
d.
Ipsilateral loss of motor function and contralateral loss of pain sensation and
temperature
10. Which level of independence is an appropriate nursing care plan goal for a patient with a C8
transection?
a.
Manage a mechanical wheelchair with a joystick.
b.
Manage a mechanical wheelchair with hand control.
c.
Manage a specially equipped wheelchair.
d.
Manage an ordinary wheelchair.
11. A paraplegic patient excitedly reports seeing his foot move when he was being turned. How is
this phenomenon best explained?
a.
Reflexive movement
b.
Return of motor function
c.
Early symptom of autonomic dysreflexia
d.
Result of hypertonicity of the muscle
12. After spinal shock has been resolved, an indwelling catheter is removed. What way should the
nurse expect this patient to empty the bladder?
a.
Manual expression (Credé method)
b.
Spontaneous reflexive action
c.
Normal voluntary control
d.
Self-catheterization
13. A distressed family member asks about the purpose of the Gardner-Wells tongs. Which is the
most helpful explanation by the nurse regarding the action of Gardner-Wells tongs?
a.
Compress the cervical vertebrae.
b.
Immobilize the head.
c.
Allow the patient to be moved out of bed.
d.
Align the cervical vertebrae.
14. What is the major advantage of the halo device over the Gardner-Wells tongs?
a.
Separates the cervical vertebrae
b.
Allows the patient out of bed
c.
Aligns the cervical spine
d.
Relieves pain
15. A patient is receiving methylprednisolone. What purpose should the nurse explain this drug
has in treating a patient with an SCI?
a.
Reduces spinal cord cellular damage
b.
Counteracts spinal shock
c.
Increases blood supply to the injured cord
d.
Enhances sexual function
16. A patient with an SCI begins to have seizures, and the blood pressure (BP) rises rapidly to
210/160 mm Hg. Which is the third indicator of the syndrome of autonomic dysreflexia?
a.
Profuse vomiting
b.
Hives on face and neck
c.
Excessive urine output
d.
Bradycardia
17. What should be the immediate intervention when a nurse recognizes autonomic dysreflexia in
the patient with an SCI?
a.
Flex the patient’s legs using the knee gatch of the bed.
b.
Cool the patient with alcohol solution.
c.
Raise the head of the bed to at least 45 degrees.
d.
Administer oxygen per mask.
18. Which intervention by a nurse is effective in the prevention of autonomic dysreflexia in the
patient with an SCI?
a.
Ensure patency of the urinary catheter.
b.
Give warm baths to the patient to stimulate vasodilation.
c.
Keep lighting at a minimum to reduce stimulation.
d.
Offer the patient four or five small meals daily.
19. A nurse tells a patient with quadriplegia that he is being treated with intravenous (IV) drugs
because this method is more effective than intramuscularly (IM). What explanation should the
nurse provide about IM medications to explain to the patient why they are less effective than
IV?
a.
Too concentrated
b.
Too irritating to poorly perfused tissue
c.
Not absorbed well below the level of the injury
d.
Too small a dose to be effective
20. The family members of a patient with an SCI, who is in the rehabilitation phase, wants to take
the patient outdoors for a visit. It is 90° F outside and very humid. What should the nurse
suggest?
a.
Do not go outside at all but remain in the hospital.
b.
Take a spray bottle to spray water to cool the patient by evaporation.
c.
Take a light sweater to insulate the patient.
d.
Have the patient drink at least 32 oz of water during the outing.
21. A nurse notes that no urinary output has occurred in a patient who underwent a laminectomy 2
hours earlier. What action should the nurse implement?
a.
Continue to monitor.
b.
Inform the charge nurse.
c.
Perform intermittent catheterizations.
d.
Turn the patient to the right side.
22. Which statement made by a male patient with an SCI could be assessed as a positive
adaptation to the nursing diagnosis of “Sexual dysfunction, related to altered body function”?
a.
“I know I will never have a sexual relationship again.”
b.
“I need some suggestions as to how to direct my sexual energy into gardening or
painting . . . or just anything.”
c.
“Can you arrange an appointment with a sex counselor so I can begin to examine
alternative methods of sexual activity?”
d.
“I think that after a while I will be able to have sexual relationships just like I had
before my accident.”
23. What should a nurse emphasize regarding the rehabilitation of the patient with an SCI?
a.
Rehabilitation is usually achieved within a few months after stabilization.
b.
Rehabilitation will return the patient with an SCI to the preaccident functional
level.
c.
Rehabilitation focuses on adjustments necessary to reenter society and the
workplace.
d.
Rehabilitation completely targets self-care.
24. What should a nurse include in a patient’s plan of care when considering interventions for the
outcome of prevention of contractures in a patient with an SCI?
a.
Apply cold wraps to the limbs twice a day.
b.
Perform full ROM exercises every 2 hours.
c.
Use significant tactile stimuli each shift.
d.
Apply splints to the limbs.
25. The family of a patient with an SCI is concerned with the lack of bowel function 2 days after
the injury. What is the best response by the nurse?
a.
“Because of his injury, he will always need to have enemas for bowel evacuation.”
b.
“Medical management is delaying bowel action because it places pressure on the
injury.”
c.
“Bowel function should return in approximately 3 days after the accident.”
d.
“We’ll just have to wait and see if bowel action returns this week.”
26. What should a nurse explain when a patient with an SCI inquires what the physician means by
a cone-down?
a.
A cone is surgically placed over the spine to protect the cord.
b.
Marks will be placed on either side of the injury to mark the area.
c.
A cone-shaped wedge of bone will be placed between the vertebrae.
d.
A detailed radiographic image will be taken of the spinal injury.
27. What should a nurse encourage a patient with an SCI to do after a computed tomography (CT)
scan?
a.
Sit up at a 30-degree angle.
b.
Prevent chilling.
c.
Drink plenty of water.
d.
Avoid bearing down.
MULTIPLE RESPONSE
28. What has occurred in the past 10 years to enhance rehabilitation of individuals with SCIs?
(Select all that apply.)
a.
Technologically advanced assistive aids
b.
Rehabilitation personnel
c.
Development of trauma centers
d.
Health insurance
e.
Rapid transport of victims
29. What changes occur with the intervertebral disks in older adults that increase the risk of
injury? (Select all that apply.)
a.
Fill with calcium deposits
b.
Are less shock absorbent
c.
Are herniated
d.
Enlarge and swell
e.
Lose water
30. Before taking a magnetic resonance image (MRI), a patient asks why metal objects and the
MRI machine are such concerns. What is the best explanation by the nurse regarding the MRI
machine? (Select all that apply.)
a.
Causes metal objects to spark, similar to a microwave
b.
Deactivates the battery in a pacemaker
c.
Causes metal to heat up and burn the patient
d.
Does not transmit clear data if metal is present
e.
Attracts any metal into the MRI chamber
31. A nurse is caring for a despondent young female patient with an SCI at C5. The patient
verbalizes concern regarding sexual dysfunction. What should the nurse assure this patient she
can still experience? (Select all that apply.)
a.
Vaginal sensation
b.
Vaginal orgasm
c.
Normal menses
d.
Intercourse
e.
Children
32. A home health nurse encourages the family of a patient with an SCI to use the assisted cough
technique. What does this technique require the caregiver to do? (Select all that apply.)
a.
Assist the patient to inhale a bronchodilator spray and then cough.
b.
Forcefully press on patient’s back below the rib cage while the patient is in the
prone position.
c.
Assist the patient to lean forward, breathe deep, and then cough.
d.
Apply pressure to diaphragm as the patient coughs.
e.
Slap the patient on upper back while the patient is in the prone position.
COMPLETION
33. A nurse refers to the _____ to assess the extent of sensory loss and specific nerve root
enervation.
