Chapter 29: Spinal Cord Injury Linton: Introduction to Medical-Surgical Nursing, 6th Edition ALL ANSWERS 100% CORRECT SPRING FALL-2022 GUARANTEED GRADE A+
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Course
NURSING CA 104 (NURSINGCA104)
Institution
Far Eastern University
1. A nurse explains that the spinal cord extends from the brainstem to the level of which vertebra?
a. Last thoracic
b. Second lumbar
c. First sacral
d. Coccygeal ANS: B
The cord starts at the brainstem and extends to the second lumbar vertebra.
DIF: Cognitive Level: Knowledge REF: p. 510 O...
1. A nurse explains that the spinal cord extends from the brainstem to the level
of which vertebra?
a. Last thoracic
b. Second lumbar
c. First sacral
d. Coccygeal
ANS: B
The cord starts at the brainstem and extends to the second lumbar vertebra.
DIF: Cognitive Level: Knowledge REF: p. 510 OBJ: N/A
TOP: Anatomy and Physiology of the Central Nervous System (CNS)
KEY: Nursing Process Step: N/A MSC: NCLEX: N/A
2. On admission to the emergency department, a patient with a C5 compression
fracture can move only his head and has flaccid paralysis of all extremities. The
distraught family asks if the paralysis is permanent. What is the best response
by the nurse?
a. Yes. In all likelihood, the paralysis is probably permanent.
b. No. Significant recovery of function should occur in a few days.
c. It is too early to tell. When the spinal shock subsides, we will know more.
d. You should talk to your physician about things of that nature.
ANS: C
Spinal shock caused by swelling may last from a few days to months, clouding
the issue of the true extent of the injury.
3. Which assessment would indicate the resolution of spinal shock?
, a. Extension and rigidity in affected limbs
b. Spastic involuntary movements in affected limbs
c. Tingling and burning in affected limbs
d. Voluntary purposeful movements of affected limbs
ANS: B
Spastic involuntary movements after a period of flaccid paralysis announce the
end of spinal shock.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Resolution of Spinal Shock KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
4. Which assessment leads the emergency department nurse to suspect that a
patients spinal cord injury (SCI) is below C4?
a. Voluntary eye movement
b. Ability to blink the eyelids
c. Unlabored respiration
d. Ability to make a facial grimace
ANS: C
The phrenic nerve, which is at C1 to C4, controls the diaphragm and intercostal
function for ventilation.
DIF: Cognitive Level: Comprehension REF: p. 516 OBJ: 3
TOP: Level of SCIs KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
5. During a neurologic assessment, a nurse asks a patient to dorsiflex the foot
against the resistance of the nurses hand. The patient is unable to perform this
action. Where does this assessment confirm that cord damage has occurred?
a. C4 to C5
b. L2 to L4
c. L5
d. S1
ANS: C
The muscle group that controls the feet is at L5.
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