
N2261 SCI
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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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