Nokea
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
- A. The patient received a blood transfusion.
- B. The patients analgesia regimen was recent changed.
- C. The patient was not repositioned during the night shift.
- D. The patients urinary catheter became occluded.
Correct Answer: D
Rationale: A distended bladder from catheter occlusion is the most common trigger for autonomic dysreflexia. Other options are less likely causes.
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A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
- A. Respiratory distress and projectile vomiting
- B. Bradycardia and hypertension
- C. Tachycardia and agitation
- D. Third-spacing and hyperthermia
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.
A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?
- A. Preparation for emergency craniotomy
- B. Watchful waiting and close monitoring
- C. Administration of inotropic drugs
- D. Fluid resuscitation
Correct Answer: B
Rationale: Nondepressed skull fractures typically require observation, not surgery, inotropes, or fluid resuscitation.
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention?
- A. Urinary retention can have serious consequences in patients with SCIs.
- B. Urinary function is permanently lost following an SCI.
- C. Urinary catheters should not remain in place for more than 7 days.
- D. Overuse of urinary catheters can exacerbate nerve damage.
Correct Answer: A
Rationale: Urinary retention risks autonomic dysreflexia and trauma in SCI patients, guiding cautious catheter removal. Urinary function loss depends on injury level, and catheters do not damage nerves.
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
- A. Placing the patient on a fluid restriction as ordered
- B. Applying thigh-high elastic stockings
- C. Administering an antifibrinolyic agent
- D. Assisting the patient with passive range of motion (PROM) exercises
Correct Answer: B
Rationale: Elastic stockings promote venous return, reducing DVT risk. Fluid restriction increases clotting risk, antifibrinolytics promote clotting, and PROM does not prevent DVT.
A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?
- A. The patient will be unable to use a wheelchair.
- B. The patient will be unable to swallow food.
- C. The patient will be continent of urine, but incontinent of bowel.
- D. The patient will require full assistance for all aspects of elimination.
Correct Answer: D
Rationale: C4 SCI causes dependency for elimination due to loss of voluntary control. Patients can use electric wheelchairs and swallow food, and continence is not preserved.