Neuro - Spinal cord injury

A nurse is explaining neurogenic shock to the family of a patient with a spinal cord injury. Which of the following statements by the family indicates a need for further education?

• “The patient is receiving atropine that will help with the low heart rate.”

• “The patient went into neurogenic shock because of the injury to the T-4 vertebrae.”

• “The patient might have paralysis and loss of deep tendon reflexes because of the neurogenic shock.”

• “The patient’s temperature will need to be monitored carefully.”

Tetraplegia can occur with which type of injury?

• C-5 spinal cord injury

• T-3 spinal cord injury

• T-6 spinal cord injury

• L-1 spinal cord injury

A client with a T-2 injury is suddenly experiencing a severe headache, diaphoresis and flushed skin above the level of injury, and blurry vision. An hour ago B/P was 126/88 and HR was 68. Which of the following would you expect to see in vital signs now?

• B/P=156/88, HR=102

• B/P=96/60, HR=115

• B/P=162/95, HR=40

• B/P=98/42, HR=36

A nurse is teaching a patient about autonomic dysreflexia. After educating the patient on s/sx and the importance of checking blood pressure, the nurse discusses potential causes. Which of the following could trigger autonomic dysreflexia? (SATA)

• Bladder distension

• Elevating the HOB to 90 degrees

• Loose clothing

• Fecal impaction

A patient comes into the ED with a confirmed C-5 injury. Which of the following orders would you question?

• Establish 2 IV access sites

• Logroll patient during transfers

• Avoid turning the patient

• Apply oxygen via nasal cannula

The nurse is educating a patient going home with a halo vest on how to care for this device. Which of the following instructions is correct?

• Clean around the pins every other day with chlorhexidine

• Sit completely upright to keep the neck neutral when loosening the brace

• Report signs of redness, tenderness, and drainage around the insertion sites

• Take oral antibiotics daily for 2 weeks

Which of the following is true about spinal shock? (SATA)

• Spinal shock does not cause low MAP

• Spinal shock symptoms often resolve on their own

• Spinal shock occurs because of spinal cord edema

• Loss of sensation will occur below the level of injury