N2261 SCI

A 47 yr old client with a spinal cord injury at T6 is being admitted to the unit. The nurse notices the client is flushed, diaphoretic and complains of a headache that is 7/10 on the pain scale. What is a priority action? 

• Vital signs

• Complete a focused cardiac assessment

• Notify the physician of the 7/10 headache

• Provide analgesia

After assessing a client who has sustained a spinal cord injury the nurse identifies that the client has variable loss of motor function, pain and temperature sensation below the level of their injury but their proprioception is maintained. The nurse identifies this as: 

• Anterior cord syndrome 

• Brown-Sequard syndrome 

• Central cord syndrome 

• Cauda Equina 

The nurse is caring for a client with a spinal cord injury. The client is downcast and states “I don’t know how anyone lives likes this? How will I still have a relationship with my partner and how will I ever enjoy my life again?” The nurse’s appropriate response to this is: 

• These are normal emotions during the healing process. 

• These are normal emotions during the healing process. 

• Explore the clients emotional state further by asking what they mean by this statement 

• Call the clients partner on their behalf to have a family meeting 

The functional outcomes for a client living with a spinal cord injury are more favorable for which type of spinal cord injury? 

• Complete SCI

• Incomplete SCI

• Incomplete SCI

• Secondary SCI

A client sustains a crushing injury of the spinal cord resulting in a complete C5 spinal cord injury. As a result of this injury, the nurse expects which of the following clinical manifestations?

• Ventricular fibrillation and decreased perfusion

• Dysfunction of the vagus nerve causing hiccups

• Retention of sensation but paralysis of the lower extremities

• Respiratory paralysis and cessation of diaphragmatic breathing

The nurse is caring for a client who has a spinal cord injury at the level of T2. The nurse identifies the client is at risk for autonomic dysreflexia. Which of the statements support the nurses rationale?

• Deep tendon reflexes have been lost

• There is damage above the sixth thoracic vertebra.

• Flaccid paralysis of the lower extremities has occurred.

• The spinal cord was partially transected.

The nurse is in the process of admitting a client for C8 tetraplegia. The nurse identifies their blood pressure as 80/40, pulse 48bpm and regular, RR 18 per minute, and temperature 36.9C. The client is flushed and cool to the periphery. The nurse identifies this as signs of which of the following?

• Autonomic dysreflexia

• Hemorrhagic shock

• Spinal shock

• Neurogenic shock

Based on the nurses knowledge of neurogenic bladder for a client living with a spinal cord injury, the nurse knows to encourage fluid intake for which of the following rationales?

• To prevent a urinary tract infection

• To maintain electrolyte balance

• To prevent dehydration

• To support normothermia

A client is admitted to the ICU with a C7 SCI, and Brown-Séquard syndrome is diagnosed. The nurse anticipates which of the following when completing their physical examination?

• Upper extremity weakness only

• Complete motor and sensory loss below C7

• Loss of position sense and vibration in both lower extremities

• Ipsilateral motor loss and contralateral sensory loss below C7

A client with a C8 SCI states they think they have the flu because of a severe headache with associated nausea. The client then asks the nurse to check their temperature. What would be the nurse's priority action?

• Check the clients temperature

• Check the clients BP and HR

• Check the clients skin

• Check the clients bowel and bladder function