Spinal Core Injury

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Sample questions from Spinal Core Injury

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 24-year-old client with a suspected cervical spinal cord injury after a diving accident has BP 82/46 mm Hg, HR 48/min, warm dry skin, and a weak cough. Which action should the nurse take first?

   • A.Place the client in Trendelenburg position and reassess in 15 minutes
   • B.Obtain a complete medication history before intervening
   • C.Apply a heating pad to the extremities
   • D.Maintain spinal alignment and support ventilation while activating the trauma response

   Rationale: The hypotension, bradycardia, and warm dry skin suggest neurogenic shock, while the weak cough signals risk of respiratory failure. Maintaining alignment and promptly supporting airway and breathing address immediate threats. Trendelenburg positioning does not correct the cause and may impair ventilation; heat risks burns, and a medication history must not delay stabilization.

2. 2.Refer to the client's chart. Which actions should the nurse take now for this 17-year-old client with an acute cervical spinal cord injury? Select all that apply.

   • A.Maintain manual in-line stabilization during airway interventions
   • B.Notify the provider immediately about the worsening respiratory measurements
   • C.Keep the client supine with the neck flexed for comfort
   • D.Administer an oral sedative before reassessing the breathing
   • E.Continue frequent respiratory and neurologic assessments
   • F.Prepare for endotracheal intubation because respiratory effort is declining

   Rationale: Manual in-line stabilization protects the injured spine, and the falling respiratory rate and vital capacity require urgent airway preparation and provider notification. Ongoing respiratory and neurologic assessments detect further deterioration. Neck flexion can worsen spinal injury, and an oral sedative can depress respirations and is unsafe with declining airway function.

3. 3.At change of shift on a spinal injury unit, a 32-year-old client with a T6 injury reports a sudden pounding headache and facial flushing. BP is 208/110 mm Hg, HR 52/min, and the bladder catheter tubing is kinked. What should the nurse do first?

   • A.Sit the client upright and unkink the catheter tubing
   • B.Place the client flat and elevate the legs
   • C.Give the prescribed PRN antihypertensive before checking for triggers
   • D.Restrict fluids for the remainder of the shift

   Rationale: This is autonomic dysreflexia, likely triggered by bladder distention; sitting upright helps lower blood pressure while the nurse removes the trigger. Laying the client flat can worsen hypertension, and a medication may be needed only if pressure remains high after prompt trigger management and according to orders. Fluid restriction does not resolve the obstruction.

4. 4.During rounds on a rehabilitation unit, a 41-year-old client with a complete T10 injury has a new order for intermittent catheterization every 4 hours. Which task is appropriate to delegate to an experienced unlicensed assistive personnel (UAP)?

   • A.Determine whether the catheterization schedule is effective
   • B.Measure and record urine output after the nurse performs catheterization
   • C.Teach the client clean intermittent catheterization
   • D.Assess the client for signs of autonomic dysreflexia

   Answer and rationale are in the full material.

5. 5.Refer to the client's chart. Which findings require immediate escalation by the nurse caring for this 28-year-old client after a T5 spinal cord injury? Select all that apply.

   • A.New abdominal distention with absent bowel sounds
   • B.Temperature 37.2 C with intact skin over the sacrum
   • C.Urine output averaging 35 mL/hr
   • D.New oxygen saturation of 89% with a weak cough
   • E.BP 78/42 mm Hg with HR 44/min and warm skin

   Answer and rationale are in the full material.