NUR 254- Unit 2.3 Practice Questions and Correct Answers
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Course
NUR 254
Institution
NUR 254
How would the nurse "grade" muscle strength for a patient who was not able to move to some resistance but not full resistance? 4 (out of 5)
A patient paralyzed from the neck down is said to have what? quadraplegia
A patient with weakness from the waist down would be documented as what? paraparesi...
NUR 254- Unit 2.3 Practice Questions
and Correct Answers
How would the nurse "grade" muscle strength for a patient who was not able to move to
some resistance but not full resistance? ✅4 (out of 5)
A patient paralyzed from the neck down is said to have what? ✅quadraplegia
A patient with weakness from the waist down would be documented as what?
✅paraparesis
A patient with spinal cord injury <8 hours ago, present with hypotension, bradycardia,
and absent reflexes and flaccid paralysis below the level of injury. What complication is
this indicative of? ✅spinal shock
The nurse would anticipate which electrolyte imbalance related to immobility for a
patient with a complete cord injury at t5? ✅hypercalcemia
At what level will a patient with complete spinal cord injury be ventilator dependent?
✅c4 (above c5)
Aside from ensuring abcs, what should the priority intervention be for a patient with
suspected spinal cord injury? ✅immobilization
A patient is at risk for autonomic dysreflexia. What are three things that could stimulate
ad? ✅full bladder/bowel, skin irritation (tight clothing, scds, etc.), pressure areas
The patient with acute spinal cord injury is receiving high dose methylprednisolone.
What is the purpose for this medication? ✅decrease inflammation and decrease
secondary injury to the spinal cord
At what level of sci will a patient be ventilator dependent? ✅c4
Above which level of injury would a patient be at high risk for neurogenic shock and ad?
✅t6
A patient is unable to move or feel from the waist down. What would this be
documented as? ✅paraplegia
A patient should be suspected as having a sci and should be immobilized until ruled out
for what reasons? ✅head trauma, gsw near spinal column, fall, mvc
, When explaining spinal shock to a family member what should the nurse say? ✅it is
like a concussion of the spinal cord and will resolve over time with increasing reflexes
and then hyperactive reflexes
A nurse stops to help after witnessing an accident involving adolescent riding a
motorcycle, hitting a tree and being thrown 30 feet into a field. The adolescent reports
that he is unable to move his legs. While waiting for ems, what should the nurse do?
✅leave the adolescent as he is, staying with him
The nurse auscultates closely for bowel sounds when assessing a patient with sci
because? ✅the complication of paralytic ileus
The family of a patient with a fresh spinal cord injury asks what the methylprednisolone
infusion is for. What should the nurse say? ✅it is to decrease inflammation and
decrease further injury to the spinal cord secondary to inflammatory response after the
initial injury
After a fall, which manifestations would indicate a potential spinal cord injury and need
to be evaluated further? ✅extreme pain/pressure in the neck or back, impaired
breathing after injury, oddly positioned neck or back, weakness, paresthesia
When distinguishing spinal shock from neurogenic shock, what may not occur with
neurogenic shock? ✅flaccid paralysis
The nurse is assessing a patient at a rehabilitation facility who is 2 months post t5
complete spinal cord injury. What manifestations would alert the nurse the patient has
developed autonomic dysreflexia? ✅hypertension, headache, nasal stuffiness,
sweating above level of injury, bradycardia
A patient 2 months post t5 complete spinal cord injury, present with sudden
hypertension of 205-110 and complaints of pounding headache. The upper body is
flushed and diaphoretic. What should the nurse do? ✅assess for skin irritation, assess
for fecal impaction, and remove all restrictive clothing
When providing care for a patient in cervical skeletal traction what is essential?
✅ensure that the weights are hanging freely
A patient involved in an auto accident has severe spinal cord injuries. If the patient is
having difficulty with diaphragmatic breathing, which level of the spinal cord is injured?
✅c6-c7
Which region consists of 12 pairs of spinal nerves? ✅thoracic region
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