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The nurse is caring for a patient with a neck fracture at the C5 level in the intensive care unit. During initial assessment of the patient, the nurse recognizes the presence of neurogenic shock upon assessing which of the following findings?
- A. Hypotension, bradycardia, and warm extremities
- B. Involuntary, spastic movements of the arms and legs
- C. Hyperactive reflex activity below the level of the injury
- D. Lack of movement or sensation below the level of the injury
Correct Answer: A
Rationale: Neurogenic shock is characterized by hypotension, bradycardia, and vasodilation leading to warm skin temperature. Spasticity and hyperactive reflexes do not occur at this stage of spinal cord injury. Lack of movement or sensation indicates spinal cord injury, but not neurogenic shock.
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The nurse is developing a rehabilitation plan for a patient with a C6 spinal cord injury. Which of the following goals should the nurse include for this patient?
- A. Transfer independently to a wheelchair.
- B. Drive a car with powered hand controls.
- C. Turn and reposition independently when in bed.
- D. Push a manual wheelchair on flat, smooth surfaces.
Correct Answer: D
Rationale: The patient with a C6 injury will be able to use the hands to push a wheelchair on flat, smooth surfaces. Because flexion of the thumb and fingers is minimal, the patient will not be able to grasp a wheelchair during transfer, drive a car with powered hand controls, or turn independently in bed.
The nurse is assessing a patient with newly diagnosed trigeminal neuralgia. Which of the following parameters should the nurse assess?
- A. Triggers that lead to facial pain
- B. Visual problems caused by ptosis
- C. Poor appetite caused by a loss of taste
- D. Weakness on the affected side of the face
Correct Answer: A
Rationale: The major clinical manifestation of trigeminal neuralgia is severe facial pain that is triggered by cutaneous stimulation of the nerve. Ptosis, loss of taste, and facial weakness are not characteristics of trigeminal neuralgia.
The nurse is caring for a patient with a T2 spinal cord injury who tells the nurse, 'I feel awful today. My head is throbbing, and I feel sick to my stomach.' Which of the following actions should the nurse take first?
- A. Assess for a fecal impaction.
- B. Give the prescribed antiemetic.
- C. Check the blood pressure (BP).
- D. Notify the health care provider.
Correct Answer: C
Rationale: The BP should be assessed immediately in a patient with an injury at the T6 level or higher who complains of a headache to determine whether autonomic dysreflexia is occurring. Notification of the patient's health care provider is appropriate after the BP is obtained. Administration of an antiemetic is indicated after autonomic dysreflexia is ruled out as the cause of the nausea. The nurse may assess for a fecal impaction, but this should be done after checking the BP and lidocaine jelly should be used when performing a digital rectal exam to prevent further symptoms such as increases in the BP.
The nurse is caring for a patient with a C3 injury who is demonstrating diaphragmatic respirations. Which of the following findings should the nurse expect to assess?
- A. Tachypnea
- B. Hypertension
- C. Hypovolemia
- D. Hypoventilation
Correct Answer: D
Rationale: Hypoventilation almost always occurs with diaphragmatic respirations because of the decrease in vital capacity and tidal volume, which occurs as a result of impairment of the intercostal muscles.
The nurse is caring for a patient who has halo traction. Which of the following traction weights should the nurse anticipate being used when the traction is first applied?
- A. 1 kg
- B. 10 kg
- C. 8 kg
- D. 5.5 kg
Correct Answer: D
Rationale: The initial weight is typically 4.5-6.8 kg and thereafter approximately 2.2 kg per level with continual neurological monitoring so the only weight value within this normal range is 5.5 kg.