Chapter 37- Spinal Cord Injury My Nursing Test Banks

 

1.

A teenaged boy jumped from a two-story building and landed on his feet, injuring his spine, and is now in the ICU. The nurse recognizes his injury as which of the following?

A)

Rotational injury

B)

Axial loading

C)

Hyperflexion

D)

Hyperextension

2.

The nurse is assessing a patient with a spinal cord injury in the ICU. The patient is completely paralyzed from the waist down but has sensation in his shoulders, chest, arms, and hands. He has no control of his bowel or bladder. Which of the following are possible sites for this patients injury, given his loss of function? Select all that apply.

A)

C4

B)

C7

C)

T3

D)

T7

E)

T12

F)

L4

3.

A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord?

A)

Central

B)

Lateral

C)

Anterior

D)

Posterior

4.

A patient involved in a snowmobile accident struck a tree and sustained a fractured vertebra at C4. She demonstrates signs of ischemic areas near the injury, along with hypoperfusion, microscopic hemorrhage, and edema. The nurse observes signs of concussion, including loss of consciousness. Which of the following are considered secondary injuries? Select all that apply.

A)

Fractured vertebra

B)

Cord ischemia

C)

Hypoperfusion

D)

Microscopic hemorrhage

E)

Edema

F)

Concussion

5.

A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient?

A)

Spinal shock

B)

Neurogenic shock

C)

Orthostatic hypotension

D)

Central cord syndrome

6.

A patient with a spinal cord injury has been stabilized in the ICU and now must undergo diagnostic testing. Which test would be most appropriate for detecting a fracture of the vertebra?

A)

Magnetic resonance imaging (MRI)

B)

Blood urea nitrogen (BUN)

C)

Glasgow coma scale (GCS)

D)

Computed tomography (CT)

7.

A patient is recovering from a lumbar spine injury and requires an immobilization device for this region. Which device would be most appropriate for this patient?

A)

Halo vest

B)

Aspen collar

C)

Minerva brace

D)

Jewett brace

8.

A nurse is monitoring a patient with spinal cord injury for respiratory complications. Which of the following findings would indicate that the patient should be intubated?

A)

Respiratory rate of 20 breaths/minute

B)

Vital capacity of 30 mL/kg

C)

PaO2 of 90 mm Hg

D)

PaCO2 of 60 mm Hg

9.

After failing to effectively clear a patients airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of?

A)

Bradycardia

B)

Tachycardia

C)

Hyperglycemia

D)

Hypertension

10.

A patient with a spinal cord injury and who smokes is at risk for developing deep vein thrombosis (DVT). The nurse provides the patient with antiembolism stockings and encourages her to stop smoking, as it contributes to vasoconstriction in the periphery and thus to DVT. What other measure would be appropriate to help prevent DVT in this patient?

A)

Administration of atropine sulfate

B)

Administration of heparin

C)

Administration of reserpine

D)

Administration of methyldopa

11.

A patient is admitted to the emergency department after a near-drowning accident. The patient dove head-first into shallow water and has a high blood-alcohol level. Cardiopulmonary resuscitation was used at the scene. The patient is awake and alert. Considering the mechanism of injury, what is the highest nursing priority?

A)

Check vital signs often.

B)

Obtain an order for radiography studies.

C)

Monitor pulse oximetry closely.

D)

Provide cervical spine stability.

12.

A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patients injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator. What is the best nursing action to provide for patient safety?

A)

Be sure all side rails are up at all times.

B)

Keep the bed in low position when unattended.

C)

Verify that a functioning bag-mask resuscitator is at the bedside.

D)

Place the call light in the patients hand.

13.

A patient was struck in the jaw and had hyperextension of the cervical spine. If the patient has central cord syndrome, what would the nurse most expect?

A)

Full loss of motor function below the lesion

B)

Ipsilateral increased cutaneous pain at the lesion

C)

Arm paralysis with intact motor function in the legs

D)

Full motor paralysis and loss of touch sensation below the lesion

14.

Patients with spinal cord injury may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock?

A)

Loss of motor and sensory function

B)

Flaccid paralysis below the lesion

C)

Presence of poikilothermia

D)

Hypotension and bradycardia

15.

During the initial assessment of patient with a probable spinal cord injury, the nurse performs a digital rectal examination. What is the best rationale for this examination?

A)

Part of routine admission physical

B)

Checks for fecal impaction

C)

Assesses for sensation or movement

D)

Preliminary for rectal medications

16.

A patient involved in a motor vehicle accident has a high risk of spinal cord injury. At the scene, what is the priority patient assessment?

A)

Level of consciousness

B)

Respiratory rate

C)

Independent mobility

D)

Peripheral sensation

17.

A patient with a cervical spine fracture has been fitted with a halo vest and is to ambulate for the first time today. What is the priority nursing action?

A)

Put rubber corks on the ends of the pins.

B)

Pad the edges of the vest to prevent chafing.

C)

Have the patient sit on the side of the bed for several minutes.

D)

Teach about loss of peripheral vision.

18.

A patient has a C7-C8 spinal cord injury. During recovery, what is the nursing priority of care?

A)

Encourage the patient to do incentive spirometry exercises.

B)

Monitor neurologic status every 4 hours.

C)

Collaborate with physical therapy for exercises.

D)

Refer to social services for financial assistance.

19.

A patient with a spinal cord lesion at C6-C7 has developed pneumonia and is placed on kinetic therapy producing constant lateral rotation to 40 degrees bilaterally. What is a nursing priority of care for this patient relative to the kinetic therapy?

A)

Measure intake and output hourly.

B)

Provide nutrition with adequate protein.

C)

Auscultate bowel sounds every 4 hours.

D)

Inspect skin surfaces every 4 hours.

20.

The patient has a spinal cord lesion at T1-T2. About an hour after being turned, the patient experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The patient has a very flushed face. What is the nursing priority?

A)

Administer pain medication immediately.

B)

Give intravenous beta-antagonist medication.

C)

Turn on a fan.

D)

Check Foley catheter for twisting or kinks.

21.

A patient recovering from a partial spinal cord lesion is experiencing muscle spasticity. Relative to this complication, what is the nursing priority?

A)

Monitor neurologic status every 4 hours

B)

Ensure compliance with exercise program

C)

Medicate often for pain and discomfort

D)

Emphasize nutritional balance

Answer Key

1.

B

2.

D, E

3.

D

4.

B, C, D, E

5.

C

6.

D

7.

D

8.

D

9.

A

10.

B

11.

D

12.

C

13.

C

14.

D

15.

C

16.

B

17.

C

18.

A

19.

D

20.

D

21.

B

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