N2261 SCI

N2261 SCI

University

10 Qs

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N2261 SCI

N2261 SCI

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10 questions

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1.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

A 47 yr old client with a spinal cord injury at T6 is being admitted to the unit. The nurse notices the client is flushed, diaphoretic and complains of a headache that is 7/10 on the pain scale. What is a priority action? 

Vital signs

Complete a focused cardiac assessment

Notify the physician of the 7/10 headache

Provide analgesia

2.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

After assessing a client who has sustained a spinal cord injury the nurse identifies that the client has variable loss of motor function, pain and temperature sensation below the level of their injury but their proprioception is maintained. The nurse identifies this as: 

Anterior cord syndrome 

Brown-Sequard syndrome 

Central cord syndrome 

Cauda Equina 

3.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

The nurse is caring for a client with a spinal cord injury. The client is downcast and states “I don’t know how anyone lives likes this? How will I still have a relationship with my partner and how will I ever enjoy my life again?” The nurse’s appropriate response to this is: 

These are normal emotions during the healing process. 

These are normal emotions during the healing process. 

Explore the clients emotional state further by asking what they mean by this statement 

Call the clients partner on their behalf to have a family meeting 

4.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

The functional outcomes for a client living with a spinal cord injury are more favorable for which type of spinal cord injury? 

Complete SCI

Incomplete SCI

Incomplete SCI

Secondary SCI

5.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

A client sustains a crushing injury of the spinal cord resulting in a complete C5 spinal cord injury. As a result of this injury, the nurse expects which of the following clinical manifestations?

Ventricular fibrillation and decreased perfusion

Dysfunction of the vagus nerve causing hiccups

Retention of sensation but paralysis of the lower extremities

Respiratory paralysis and cessation of diaphragmatic breathing

6.

MULTIPLE CHOICE QUESTION

30 sec • 1 pt

The nurse is caring for a client who has a spinal cord injury at the level of T2. The nurse identifies the client is at risk for autonomic dysreflexia. Which of the statements support the nurses rationale?

Deep tendon reflexes have been lost

There is damage above the sixth thoracic vertebra.

Flaccid paralysis of the lower extremities has occurred.

The spinal cord was partially transected.

7.

MULTIPLE CHOICE QUESTION

2 mins • 1 pt

The nurse is in the process of admitting a client for C8 tetraplegia. The nurse identifies their blood pressure as 80/40, pulse 48bpm and regular, RR 18 per minute, and temperature 36.9C. The client is flushed and cool to the periphery. The nurse identifies this as signs of which of the following?

Autonomic dysreflexia

Hemorrhagic shock

Spinal shock

Neurogenic shock

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