The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident. The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The nurse recognizes this condition as which of the following?
A) Central cord syndrome
B)...
Spinal Cord Injury (NCLEX) Latest Exam
Questions With Complete Correct
Solutions.
The nurse is caring for a patient admitted with a spinal cord injury following a motor vehicle accident.
The patient exhibits a complete loss of motor, sensory, and reflex activity below the injury level. The
nurse recognizes this condition as which of the following?
A) Central cord syndrome
B) Spinal shock syndrome
C) Anterior cord syndrome
D) Brown-Séquard - Answer Correct Answer(s): B
About 50% of people with acute spinal cord injury experience a temporary loss of reflexes, sensation,
and motor activity that is known as spinal shock. Central cord syndrome is manifested by motor and
sensory loss greater in the upper extremities than the lower extremities. Anterior cord syndrome results
in motor and sensory loss but not reflexes. Brown-Séquard syndrome is characterized by ipsilateral loss
of motor function and contralateral loss of sensory function.
Which of the following clinical manifestations would the nurse interpret as representing neurogenic
shock in a patient with acute spinal cord injury?
A) Bradycardia
B) Hypertension
C) Neurogenic spasticity
D) Bounding pedal pulses - Answer Correct Answer(s): A
Neurogenic shock is due to the loss of vasomotor tone caused by injury and is characterized by
hypotension and bradycardia. Loss of sympathetic innervation causes peripheral vasodilation, venous
pooling, and a decreased cardiac output.
The nurse is caring for a patient admitted 1 week ago with an acute spinal cord injury. Which of the
following assessment findings would alert the nurse to the presence of autonomic dysreflexia?
A) Tachycardia
B) Hypotension
C) Hot, dry skin
, D) Throbbing headache - Answer Correct Answer(s): D
Autonomic dysreflexia is related to reflex stimulation of the sympathetic nervous system reflected by
hypertension, bradycardia, throbbing headache, and diaphoresis.
When planning care for a patient with a C5 spinal cord injury, which nursing diagnosis is the highest
priority?
A) Risk for impairment of tissue integrity caused by paralysis
B) Altered patterns of urinary elimination caused by quadriplegia
C) Altered family and individual coping caused by the extent of trauma
D) Ineffective airway clearance caused by high cervical spinal cord injury - Answer Correct Answer(s): D
Maintaining a patent airway is the most important goal for a patient with a high cervical fracture.
Although all of these are appropriate nursing diagnoses for a patient with a spinal cord injury, respiratory
needs are always the highest priority. Remember the ABCs.
Which of the following signs and symptoms in a patient with a T4 spinal cord injury should alert the
nurse to the possibility of autonomic dysreflexia?
A) Headache and rising blood pressure
B) Irregular respirations and shortness of breath
C) Decreased level of consciousness or hallucinations
D) Abdominal distention and absence of bowel sounds - Answer Correct Answer(s): A
Among the manifestations of autonomic dysreflexia are hypertension (up to 300 mm Hg systolic) and a
throbbing headache. Respiratory manifestations, decreased level of consciousness, and gastrointestinal
manifestations are not characteristic.
Which of the following interventions should the nurse perform in the acute care of a patient with
autonomic dysreflexia?
A) Urinary catheterization
B) Administration of benzodiazepines
C) Suctioning of the patient's upper airway
D) Placement of the patient in the Trendelenburg position - Answer Correct Answer(s): A
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