Preview Extract
Chapter 32
1. A nurse recognizes that an example of a major source of spinal cord injuries (SCIs) in
persons aged 30 years and younger is a:
1. Motorcycle accident.
2. Fall down a flight of stairs.
3. Diving accident.
4. Schwannomas tumor.
Answer: Motorcycle accident.
Rationale:
The vast majority of SCIs are the result of a traumatic event. The most common cause of
SCIs in persons under the age of 65 is motor vehicle crashes. Falls rank as the most common
cause of SCI in people over the age of 65. Spinal cord injuries due to nontraumatic causes are
more likely to occur in persons older than 40 years of age. Schwannomas tumors are seen
most commonly in women over the age of 40.
2. In a community education presentation, a nurse should plan to include which of the
following as factors that contribute to the heightened risk for spinal cord injuries (SCI) in the
older adult population?
Select all that apply.
1. Hypertrophy of spinal ligaments
2. Bone spurs on the spinal column
3. Osteoporosis of the vertebra
4. Diabetes mellitus
5. Cardiac induced syncope
Answer: 1. Hypertrophy of spinal ligaments
2. Bone spurs on the spinal column
3. Osteoporosis of the vertebra
Rationale:
Hypertrophy of spinal ligaments. The elderly are at increased risk of injury to the spinal cord
because of degenerative changes in the spinal column, including ossification and hypertrophy
of the spinal ligaments. Bone spurs on the spinal column. The elderly are at increased risk of
injury to the spinal cord because of degenerative changes in the spinal column, including
development of bone spurs within the spinal column leading to narrowing of the spinal canal.
Osteoporosis of the vertebra. Weakening of the bone due to osteoporosis also increases the
risk of spinal fracture in these patients. Diabetes mellitus. This patient population presents an
added challenge to the management of acute SCI after it occurs because of preexisting
medical problems such as diabetes. Cardiac induced syncope. This patient population
presents an added challenge to the management of acute SCI after it occurs because of
preexisting medical problems such as heart disease, as well as the normal physiological
effects of aging.
3. When speaking to a group of teenagers regarding risky behaviors that can lead to spinal
cord injuries (SCI), the nurse should mention:
Select all that apply.
1. Not appointing a designated driver.
2. Diving into unfamiliar water.
3. Refusing to wear a helmet while dirt-biking.
4. Wearing leather-soled shoes.
5. Forgetting to wear prescription glasses.
Answer: 1. Not appointing a designated driver.
2. Diving into unfamiliar water.
3. Refusing to wear a helmet while dirt-biking.
Rationale:
Not appointing a designated driver. The key to reducing the incidence of these injuries is to
decrease high-risk behaviors such as driving while under the influence of drugs or alcohol.
Diving into unfamiliar water. The key to reducing the incidence of these injuries is to
decrease high-risk behaviors such as diving into shallow water. Refusing to wear a helmet
while dirt-biking. The key to reducing the incidence of these injuries is to decrease high-risk
behaviors such as lack of seat belt and helmet use. Wearing leather-soled shoes. Falls are
more of a risk factor for the older population, so wearing rubber-soled shoes would be more
appropriate for that population. Forgetting to wear prescription glasses. Falls are more of a
risk factor for the older population, so remembering one’s glasses would be more appropriate
for that population.
4. The nursing assessment confirms that the client has experienced loss of voluntary motor
and sensory function of both upper and lower extremities, as well as bowel and bladder
control, due to a spinal cord injury (SCI). The nurse recognizes that which of the following is
true regarding this client?
Select all that apply.
1. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.
2. Tetraplegia is a term that describes these neurological deficiencies.
3. All deep tendon reflexes are affected.
4. This client has experienced an incomplete spinal injury.
5. The client is likely to regain only limited motor control.
Answer: 1. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.
2. Tetraplegia is a term that describes these neurological deficiencies.
3. All deep tendon reflexes are affected.
Rationale:
The injury was likely a result of trauma to the C1 to C4 level of the spinal cord. An injury at
this level will exhibit all of the identified symptoms. Tetraplegia is a term that describes these
neurological deficiencies. Injuries involving the cervical spinal cord will result in tetraplegia
(a Greek term; quadriplegia is the Latin term), or loss of motor and sensory function
involving both upper extremities, both lower extremities, bowel, and bladder. All deep tendon
reflexes are affected. The client’s injuries would result in deep tendon reflex involvement.
This client has experienced an incomplete spinal injury. A complete spinal cord injury
indicates complete loss of voluntary motor and sensory functions below the level of injury.
The client is likely to regain only limited motor control. The damage to the spinal cord in this
type of injury is irreversible.
5. The nurse is caring for a client who has been diagnosed with an incomplete spinal cord
injury (SCI) that has resulted in central cord syndrome. The nurse expects that:
Select all that apply.
1. The client has preexisting degenerative bone changes.
2. This is likely a result of a hyperextension injury to the cervical spine.
3. Function, if restored, will occur first in the hands.
4. Prognosis for recovery is poor.
5. Loss of function will be greatest in the lower extremities.
Answer: 1. The client has preexisting degenerative bone changes.
2. This is likely a result of a hyperextension injury to the cervical spine.
Rationale:
The client has preexisting degenerative bone changes. Central cord syndrome is the most
common incomplete SCI. This injury can occur at any age, but is seen most frequently in
older patients who have degenerative bony changes in the cervical spine resulting in
narrowing of the overall diameter of the spinal canal. This is likely a result of a
hyperextension injury to the cervical spine. It most often is caused by a hyperextension injury
resulting in damage to the center of the spinal cord. Function, if restored, will occur first in
the hands. The typical pattern of recovery is return of lower extremity function first followed
by return of bladder function. Recovery of hand intrinsic function is variable and often the
last to return. Prognosis for recovery is poor. The overall prognosis for recovery from this
injury is generally favorable. Loss of function will be greatest in the lower extremities. There
is greater loss of motor and sensory function in the upper extremities than in the lower
extremities.
6. A client who has experienced an incomplete spinal cord injury (SCI) is most expected to:
1. Experience some neurotransmission of impulses.
2. Have sensory function restored first.
3. Be subjected to only a mild motor deficiency.
4. Experience a good prognosis for recovery.
Answer: Experience some neurotransmission of impulses.
Rationale:
Patients who have experienced an incomplete spinal cord injury will have some preservation
of sensory and/or motor function below the level of injury. In these patients, there is sparing
of some of the spinal cord tracts, which allows neurotransmission to occur. Five main
syndromes are associated with incomplete SCI, each classified according to the portion of the
spinal cord damaged and the preservation of function below the level of injury. Prognosis,
restoration of function, and degree of motor and sensory loss are specific to the resulting
syndrome.
7. A client with an incomplete spinal cord injury is being transferred from intensive care to
the neurological trauma unit. The nurse realizes that in order to minimize the risk of the client
developing autonomic hyperreflexia, the following interventions should be included in the
client’s care plan:
Select all that apply.
1. Bladder scan post-voiding
2. Strict output monitoring
3. Assessing for abdominal distention
4. Monitoring skin temperature in lower extremities
5. Assessing pulse oximetry levels with vitals
Answer: 1. Bladder scan post-voiding
2. Strict output monitoring
3. Assessing for abdominal distention
Rationale:
Bladder scan post-voiding. The nurse should be attuned to the prevention of a distended
bladder when caring for spinal cord injury (SCI) clients in order to prevent the chain of
events that leads to autonomic hyperreflexia. Scan the bladder post-voiding to determine the
presence of residual urine retention. Strict output monitoring. Track urinary output carefully
to determine the presence of residual urine retention. Assessing for abdominal distention.
Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for
abdominal distention is appropriate. Monitoring skin temperature in lower extremities.
Monitoring lower extremity skin temperature is appropriate for detecting deep vein
thrombosis. Assessing pulse oximetry levels with vitals. Pulse oximetry is effective in
monitoring for a decline in oxygen saturation and may be the initial indicator of a pulmonary
emboli.
8. A client is admitted after a fall that has resulted in spinal shock. When asked by the client’s
family how long the existing paralysis is likely to last, the nurse’s response is based on the
knowledge that:
1. The severity of the injuries cannot be determined until the spinal shock resolves.
2. Spinal shock is irreversible and the paralysis is likely to be permanent.
3. There will likely be some minor improvement in the degree of paralysis.
4. Spinal shock usually results in temporary paralysis.
Answer: The severity of the injuries cannot be determined until the spinal shock resolves.
Rationale:
Spinal shock is a state of areflexia in which there is a loss of all motor, sensory, and reflex
activity at the level of the injury and below. Spinal shock occurs as a result of the primary
injury. The duration of spinal shock is quite variable, lasting as little as a few hours or as long
as several weeks after injury. During this state, it is impossible to determine the extent of the
SCI. At this point in time, it is not possible to determine whether the paralysis is temporary,
permanent, or will lessen.
9. A client with a spinal cord injury is at risk for complications to the gastrointestinal system.
The nursing intervention primarily directed at minimizing this risk is:
1. Insertion of a nasogastric tube.
2. Administration of a lansoprazole (Prevacid).
3. Elevating the end of the bed to 35 degrees.
4. Regular assessment of the client’s bowel sounds.
Answer: Insertion of a nasogastric tube.
Rationale:
Gastrointestinal effects of spinal shock include gastroparesis, loss of intestinal peristalsis, and
ileus. Placement of a nasogastric or oral gastric tube will be necessary in the acute phase of
SCI for decompression of the stomach. Prevacid is a proton pump inhibiter that is used in the
treatment of GERD. Elevating the head of the bed is appropriate once the nasogastric tube
has been placed. Regular assessment of bowel sounds will help determine the presence or
absence of peristalsis.
10. Clients who have experienced spinal cord injuries (SCI) are faced with many challenges.
After assessing a client who has been admitted for rehabilitation after a fall that resulted in
hemiplegia, the nurse recognizes that the client’s care plan related to psychosocial concerns
may require inclusion of nursing diagnoses regarding:
Select all that apply.
1. Body image.
2. Independence.
3. Role performance.
4. Sensory perception.
5. Mobility.
Answer: 1. Body image.
2. Independence.
3. Role performance.
Rationale:
Body image. Patients who have experienced an SCI experience significant psychosocial
impact. These patients are faced with changes related to loss of body image. Independence.
Patients who have experienced an SCI experience significant psychosocial impact. These
patients are faced with changes related to loss of independence. Role performance. Patients
who have experienced an SCI experience significant psychosocial impact. These patients are
faced with changes related to previous personal and interpersonal roles. Sensory perception.
Sensory perception relates to physiological changes. Mobility. Mobility relates to
physiological changes.
11. The nurse is preparing to discuss discharge planning with a patient who is hemiplegic as a
result of a diving accident, and with his wife, who will be his primary caregiver. Knowledge
of the psychosocial needs of the caregiver prompts the nurse to include information
specifically related to:
Select all that apply.
1. Role changes.
2. Stress management techniques.
3. Respite resources.
4. Bowel and bladder management techniques.
5. Local rehabilitation services.
Answer: 1. Role changes.
2. Stress management techniques.
3. Respite resources.
Rationale:
Role changes. Patients who have experienced a spinal cord injury are not only faced with the
physical challenges associated with this injury, but the patient’s family members also will
need support and ongoing education to help them deal with the stress of having a critically ill
loved one and the role changes associated with becoming a primary caregiver. Stress
management techniques. In addition to the patient’s needs, the patient’s family members also
will need support and ongoing education to help them deal with the stress of having a
critically ill loved one. Stress management is important to the physical and mental health of
the caregiver. Respite resources. Respite options are important to the physical and mental
health of the caregiver. Bowel and bladder management techniques. Information about care
techniques addresses physiological issues. Exploring the spouse’s concerns about providing
this care would be directed at psychosocial issues. Local rehabilitation services.
Rehabilitation services are by definition interdisciplinary, addressing physiological and
psychosocial needs. Services are provided to the patient and all family members, not just the
primary caregiver.
12. Holistic care requires that nurses be competent in providing attention that addresses the
client’s needs in areas that are:
Select all that apply.
1. Physical.
2. Emotional.
3. Psychosocial.
4. Spiritual.
5. Occupational.
Answer: 1. Physical.
2. Emotional.
3. Psychosocial.
4. Spiritual.
Rationale:
Physical. An essential component in providing holistic care to patients is providing care on all
levels, including physical needs. Emotional. An essential component in providing holistic
care to patients is providing care on all levels, including emotional needs. Psychosocial. An
essential component in providing holistic care to patients is providing care on all levels,
including psychosocial needs. Spiritual. An essential component in providing holistic care to
patients is providing care on all levels, including spiritual needs. Occupational. The nurse
must be aware of all aspects of the patient’s care, but will not be the primary provider of care
related to occupational needs.
13. Spinal cord injuries (SCI) often require lengthy, intensive physical rehabilitation that is
provided by a comprehensive plan team that is comprised primarily of:
Select all that apply.
1. Occupational therapists.
2. Physical therapists.
3. Nurses.
4. Social workers.
5. Dietitians.
Answer: 1. Occupational therapists.
2. Physical therapists.
3. Nurses.
4. Social workers.
Rationale:
Occupational therapists. During the rehabilitation period, the patient will undergo extensive
inpatient occupational therapy. Physical therapists. During the rehabilitation period, the
patient will undergo extensive inpatient physical therapy. Nurses. Nurses are an integral part
of the multidisciplinary team, providing a common link for all team members as well as
providing education and support to the patient and family through all phases of treatment.
Social workers. A social worker and psychologist will work with patients and their families to
assist with psychosocial issues. Dietitians. Dietary consultation is helpful in the acute phase
of care to ensure the patient’s nutritional requirements are met. Consultation will be initiated
again in the rehab phase if needed.
14. A client with a spinal cord injury (SCI) that has resulted in paraplegia has expressed
doubts about “ever being able to give birth to children.” The nurse formulates the best
response to the client’s concern based on the understanding that:
1. Becoming a biological mother is usually possible regardless of an SCI.
2. Being sexually active will require a supportive partner.
3. Ability to function sexually will be determined by her ability to accept the physical
limitations.
4. Conception is usually by artificial insemination.
Answer: Becoming a biological mother is usually possible regardless of an SCI.
Rationale:
Patients will receive advice on maintaining an active lifestyle within the limitations of their
injury. It is important that these patients understand that they can continue to be sexually
active despite their injury. It is even possible for them to have children in the future if they so
desire. While having a supportive sexual partner and acceptance of physical limitations will
be factors in reestablishing sexual activity, they do not directly address the client’s concerns.
Most women with spinal cord injuries remain fertile and can conceive and bear children.
15. The nurse recognizes that the rehabilitation goal for a client who has experienced a spinal
cord injury (SCI) is to assist the client in:
Select all that apply.
1. Adapting to the realization of the client’s limitations.
2. Reaching the client’s highest potential for independence.
3. Assimilating back into the client’s home environment.
4. Dealing with the physical pain such injuries cause.
5. Providing the emotional support required for this adjustment.
Answer:
1. Adapting to the realization of the client’s limitations.
2. Reaching the client’s highest potential for independence.
3. Assimilating back into the client’s home environment.
Rationale:
Adapting to the realization of the client’s limitations. Rehabilitation for patients with SCI will
consist of a comprehensive program designed to help patients adapt to the limitations of their
injury. Reaching the client’s highest potential for independence. Rehabilitation for patients
with SCI will consist of a comprehensive program designed to help patients reach the highest
level of independence possible. Assimilating back into the client’s home environment.
Rehabilitation for patients with SCI will consist of a comprehensive program designed to
help patients adapt to reintegrate into the home environment and community. Dealing with
the physical pain such injuries cause. Physical pain is addressed by the medical and nursing
treatment plans. Providing the emotional support required for this adjustment. Emotional
support is the expertise of psychiatry.
16. Subjective assessment of the psychosocial state of a client who has experienced a spinal
cord injury (SCI) can be best achieved when the nurse:
1. Asks the client to identify members of his support system.
2. Enters the room and finds the client crying.
3. Is told by the client that he was once treated for depression.
4. Overhears the client telling family that “this just isn’t fair.”
Answer: Asks the client to identify members of his support system.
Rationale:
Subjective assessment of a client’s psychosocial state is best achieved by assessing the
client’s own perception of the presence of a support system. Crying is an objective sign.
Expressing a feeling of unfairness relates more to the client’s ability to cope. A history of
depression is not necessarily proof of current depression.
17. A client with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective
Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which of the
following interventions in the client’s plan of care to best address this issue?
Select all that apply.
1. Utilize abdominal binder and thigh-high compression stockings.
2. Administer vasoactive agents and atropine as ordered.
3. Strictly monitor and document intake and output.
4. Administer anticoagulant medication as ordered.
5. Assess color, temperature, and size of extremities.
Answer: 1. Utilize abdominal binder and thigh-high compression stockings.
2. Administer vasoactive agents and atropine as ordered.
3. Strictly monitor and document intake and output.
Rationale:
Utilize abdominal binder and thigh-high compression stockings. Utilization of abdominal
binder and thigh high compression stockings will help venous blood return and minimize
blood pooling in the abdomen and lower extremities. Administer vasoactive agents and
atropine as ordered. Administer vasoactive agents and atropine as ordered to ensure adequate
blood pressure, heart rate, and cardiac output. Strictly monitor and document intake and
output. Monitor intake and output and replace intravascular volume to ensure adequate fluid
status. Administer anticoagulant medication as ordered. Administering anticoagulant as
ordered is for the prevention of peripheral DVT. Assess color, temperature, and size of
extremities. Assessing color, temperature, and size of extremities enables early detection and
prompt treatment of DVT.
18. Risk for constipation related to impaired gastric motility is added to the nursing care plan
of a client with a spinal cord injury (SCI). The nurse identifies appropriate nursing
interventions as:
Select all that apply.
1. Administer stool softener as prescribed.
2. Institute mechanical stimulation to initiate bowel evacuation.
3. Encourage diet that includes high-fiber foods daily.
4. Encourage fluid intake of 8 to 10 cups daily.
5. Check each stool for occult blood.
Answer: 1. Administer stool softener as prescribed.
2. Institute mechanical stimulation to initiate bowel evacuation.
3. Encourage diet that includes high-fiber foods daily.
4. Encourage fluid intake of 8 to 10 cups daily.
Rationale:
Administer stool softener as prescribed. To minimize the risk of constipation in clients with
SCI, the nurse should institute a bowel regimen of stool softener to help establish a regular
bowel elimination pattern. Institute mechanical stimulation to initiate bowel evacuation. To
minimize the risk of constipation in clients with SCI, the nurse should institute a bowel
regimen of chemical stimulation such as a suppository to establish a regular bowel
elimination pattern. The patient’s bowel elimination pattern should be monitored closely to
ensure adequate bowel evacuation. Encourage diet that includes high-fiber foods daily.
Dietary recommendations to aid in bowel evacuation include ensuring a minimum of 15
grams of dietary fiber per day. Encourage fluid intake of 8 to 10 cups daily. Dietary
recommendations to aid in bowel evacuation include adequate fluid intake. Check each stool
for occult blood. Testing stool for occult blood is directed toward monitoring for a bleeding
gastric ulcer.
Test Bank for Timby's Introductory Medical-Surgical Nursing
Loretta A Donnelly-Moreno, Brigitte Moseley
9781975172237, 9781975172268
