Spinal Cord Injury Nursing Interventions

Front

A patient has a spinal cord injury at T4. Vital signs include falling BP with bradycardia. The nurse recognizes that the patient is experiencing:

Back

Neurogenic shock from massive vasodilation

Answer explanation

RATIONALES:

Neurogenic shock is a hemodynamic phenomenon that causes hypotension and bradycardia. This is due to massive vasodilation and not related to fluid loss.

Front

A patient with a spinal cord injury is being monitored for signs of spinal shock. Which of the following is the primary characteristic of spinal shock? Severe hypotension, bradycardia, and loss of autonomic control.

Back

Severe hypotension, bradycardia, and loss of autonomic control.

Answer explanation

Severe hypotension, bradycardia, and loss of autonomic control.

Rationale:
Spinal shock typically occurs immediately after a spinal cord injury and is characterized by hypotension, bradycardia, and loss of autonomic reflexes, including loss of sensation and motor function below the level of injury. It may last from a few hours to several weeks.

Front

A nurse is planning discharge for a patient with a recent spinal cord injury at the T12 level. Which of the following long-term care needs should the nurse prioritize for this patient? Options: Initiating early rehabilitation and physical therapy to improve mobility., Educating the patient on how to live independently without the need for assistance., Providing education on preventing pressure ulcers and promoting skin integrity., Focusing solely on teaching the patient to manage pain and spasticity.

Back

Providing education on preventing pressure ulcers and promoting skin integrity.

Answer explanation

Providing education on preventing pressure ulcers and promoting skin integrity.

Rationale:
Skin integrity is a critical concern for patients with spinal cord injuries, especially those with limited mobility. The nurse should prioritize education on preventing pressure ulcers, as these can lead to serious complications. Rehabilitation and other care needs will follow, but skin care is essential.

Front

A patient with a spinal cord injury at the C5 level is admitted to the emergency department. The nurse notes that the patient has difficulty breathing. What is the first intervention the nurse should perform?

Back

Intubate the patient and initiate mechanical ventilation.

Answer explanation

Intubate the patient and initiate mechanical ventilation.

Rationale:
Patients with high-level spinal cord injuries, such as at C5, often experience respiratory distress due to paralysis of the diaphragm and other respiratory muscles. Intubation and mechanical ventilation may be required to maintain adequate ventilation.

Front

A patient with a suspected spinal cord injury is brought into the emergency department after a motor vehicle accident. What should be the nurse’s priority during the initial assessment?

Back

Stabilizing the cervical spine to prevent further injury.

Answer explanation

C. Stabilizing the cervical spine to prevent further injury.

Rationale:
The first priority in managing a patient with a suspected spinal cord injury is to stabilize the cervical spine to prevent further damage. This can be done using manual immobilization and application of a cervical collar until proper imaging and further assessment can be completed.

Front

A patient with a spinal cord injury at T6 develops a sudden increase in blood pressure, severe headache, and diaphoresis. The nurse suspects autonomic dysreflexia. Which intervention should the nurse perform first?

Back

Immediately check for the cause of autonomic dysreflexia, such as a full bladder.

Answer explanation

Immediately check for the cause of autonomic dysreflexia, such as a full bladder.

Rationale:
The first step in managing autonomic dysreflexia is to identify and address the underlying cause, such as a distended bladder, impacted bowel, or tight clothing. Once the precipitating cause is addressed, the blood pressure will often decrease. Medication may be used if needed, but resolving the cause is the priority.