ATI Medical Surgical Spinal Cord]

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Sample questions from ATI Medical Surgical Spinal Cord]

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

1. 1.In a rehabilitation unit, a client with a T4 spinal cord injury reports a sudden pounding headache and blurred vision. The blood pressure is 204/108 mm Hg, compared with a baseline of 108/66 mm Hg, and the client has a flushed face and nasal congestion. Which action should the nurse take first?

   • A.Encourage the client to drink water and reassess in 30 minutes
   • B.Administer the prescribed antihypertensive before assessing for a trigger
   • C.Place the client supine and elevate the legs
   • D.Sit the client upright and loosen restrictive clothing

   Rationale: Sitting the client upright and loosening restrictive clothing helps lower blood pressure while the nurse promptly searches for and removes the trigger of autonomic dysreflexia. Lying supine can further increase blood pressure, and delaying assessment to give medication or wait risks a hypertensive emergency. The exam priority is to reduce immediate risk while identifying common triggers such as bladder distention or bowel impaction.

2. 2.A client with a new C6 spinal cord injury has warm, dry skin, a blood pressure of 78/42 mm Hg, and a heart rate of 46/min. Which interpretation should guide the nurse's immediate care?

   • A.Hypovolemic shock is likely because spinal cord injury commonly causes acute blood loss
   • B.Autonomic dysreflexia is likely because the client has a high-level injury
   • C.Neurogenic shock is likely because sympathetic disruption can cause hypotension and bradycardia
   • D.The findings are expected during spinal shock and require no intervention

   Rationale: A high spinal cord injury can disrupt sympathetic tone, producing vasodilation, hypotension, and bradycardia characteristic of neurogenic shock. Hypovolemic shock remains a consideration after trauma, but the combination of warm, dry skin and bradycardia is more consistent with neurogenic shock than typical blood-loss shock. Autonomic dysreflexia causes severe hypertension, not hypotension, and these unstable findings require immediate treatment rather than observation.

3. 3.Refer to the client's chart. Which actions should the nurse take in response to the current findings? Select all that apply.

   • A.Assess the urinary catheter tubing for kinks or obstruction
   • B.Elevate the head of the bed and lower the legs
   • C.Keep the client flat while obtaining a complete set of routine measurements
   • D.Recheck blood pressure frequently while continuing to identify the trigger
   • E.Check the bladder for distention and address urinary retention per protocol

   Rationale: The chart shows a rapid rise in blood pressure from 110/68 to 196/104 mm Hg with headache, flushing, and a kinked catheter, findings consistent with autonomic dysreflexia. Elevating the head and lowering the legs can reduce blood pressure, and relieving the catheter obstruction or bladder distention addresses a likely trigger. Frequent blood pressure reassessment is necessary because the client remains at risk while the trigger is treated. Keeping the client flat can worsen hypertension, and routine measurements must not delay immediate positioning and trigger assessment.

4. 4.During a home visit, a client with a T8 spinal cord injury reports dizziness when moving from bed to wheelchair. Blood pressure changes from 118/72 mm Hg supine to 86/54 mm Hg after sitting, and the client becomes pale. Which instruction is most appropriate?

   • A.Wear an abdominal binder only after symptoms begin
   • B.Use gradual position changes and pause at the bedside before transferring
   • C.Perform a rapid transfer to shorten the time spent sitting
   • D.Restrict fluids before transfers to prevent bladder distention

   Answer and rationale are in the full material.

5. 5.At change of shift, four clients with spinal cord injuries need assessment. Which client should the nurse see first?

   • A.A client with a T3 injury who has a new severe headache and blood pressure of 188/100 mm Hg
   • B.A client with a T10 injury who reports no bowel movement for 2 days
   • C.A client with a C7 injury who requests assistance adjusting a wheelchair footrest
   • D.A client with a T12 injury who has mild ankle edema after sitting upright

   Answer and rationale are in the full material.