Med-Surg Spinal Cord

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Sample questions from Med-Surg Spinal Cord

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

1. 1.A client with a T4 spinal cord injury reports a sudden pounding headache and blurred vision during bowel care. The face is flushed and diaphoretic above the injury; the client is pale below it. Which action should the nurse take first?

   • A.Check the rectum for retained stool using a gloved finger.
   • B.Place the client supine and elevate the legs.
   • C.Sit the client upright and loosen constrictive clothing.
   • D.Administer the prescribed PRN antihypertensive medication.

   Rationale: The headache, flushing, and marked blood pressure response suggest autonomic dysreflexia, and sitting the client upright can lower blood pressure while the trigger is addressed. A PRN antihypertensive may be needed if hypertension persists, but positioning is an immediate first action. Rectal assessment may identify a trigger, but should follow measures to reduce blood pressure; lying supine can worsen it. The exam takeaway is to sit the client upright, loosen restrictive items, and promptly search for and remove the noxious stimulus.

2. 2.Refer to the client's chart. Which actions should the nurse take now to address the client's acute condition? Select all that apply.

   • A.Inspect the urinary drainage tubing for kinks or obstruction.
   • B.Loosen the abdominal binder and other restrictive clothing.
   • C.Place the client flat and elevate the legs.
   • D.Notify the provider if severe hypertension persists after initial measures.
   • E.Raise the head of the bed and lower the legs.
   • F.Continue bowel care until the stool is completely removed.

   Rationale: The sudden headache and hypertension, with blood pressure rising from 118/72 to 204/110 mm Hg during bladder care, are consistent with autonomic dysreflexia in a client with a T3 injury. Raising the head, loosening restrictive clothing, and checking the catheter system address immediate safety and common triggers; persistent severe hypertension requires prompt escalation. Lying flat can worsen hypertension, and continuing bowel care before stabilizing the client may intensify the episode. The exam takeaway is to stop the provoking activity, reduce blood pressure through positioning, and investigate common triggers such as bladder distention.

3. 3.A client with an acute T6 spinal cord injury has warm, dry skin, a blood pressure of 78/40 mm Hg, and a heart rate of 42/min. Which interpretation should guide the nurse's immediate actions?

   • A.Neurogenic shock is likely; support perfusion and anticipate vasopressor therapy.
   • B.Hemorrhagic shock is established; restrict fluids to prevent edema.
   • C.Spinal shock is causing hypotension; administer a prescribed antipyretic.
   • D.Autonomic dysreflexia is occurring; sit the client upright.

   Rationale: Hypotension with bradycardia and warm, dry skin after a high spinal injury is characteristic of neurogenic shock from loss of sympathetic tone. The nurse should support perfusion and anticipate ordered fluid and vasopressor management while monitoring closely. Spinal shock describes transient loss of reflexes and motor, sensory, and autonomic function below the lesion, not this hemodynamic pattern; an antipyretic does not treat it. Autonomic dysreflexia causes acute hypertension, not profound hypotension.

4. 4.During a home visit, a client with a chronic T8 spinal cord injury reports lightheadedness after transferring to a wheelchair. Blood pressure falls from 126/78 mm Hg supine to 88/56 mm Hg sitting, without a change in heart rate. Which teaching is most appropriate?

   • A.Increase the speed of transfers to shorten the time upright.
   • B.Limit fluid intake before transfers to reduce bladder distention.
   • C.Take an extra dose of the prescribed antihypertensive before sitting.
   • D.Use a gradual position change and an abdominal binder as prescribed.

   Answer and rationale are in the full material.

5. 5.An older adult with a recent spinal cord injury is prescribed enoxaparin for venous thromboembolism prophylaxis. The platelet count has fallen from 214,000/mm3 to 92,000/mm3 over 5 days. Which action should the nurse take?

   • A.Continue the medication because thrombocytopenia is expected during immobility.
   • B.Hold the next dose and notify the provider about possible heparin-induced thrombocytopenia.
   • C.Administer the dose and recheck the platelet count in one week.
   • D.Give vitamin K and continue the prophylaxis regimen.

   Answer and rationale are in the full material.