NCLEX Review Questions (Wagner) - Chapter (19)

Chapter 19: Acute Spinal Cord Injury NCLEX® Review This activity contains 10 questions. A client is brought to the Emergency Department after sustaining a spinal injury in a boating accident. The diagnosis of unstable spinal injury is made. How should the nurse interpret this information? Total flaccid paralysis is the determining factor for making this diagnosis. The client's injury includes disruption of two or more of the spinal columns and close attention must be paid to decrease the chance of secondary injury. This diagnosis is not made unless there are associated hemodynamic changes the nurse will need to manage. The client will have a maximal degree of sensory impairment. A nurse is applying for a position at a facility where care is provided to clients who have incomplete spinal cord injuries. The nurse can expect to care for clients with which condition? Paraplegia Brown-Sequard syndrome Tetraplegia Quadriplegia A client is brought to the Emergency Department after being injured in a head-on car accident. The nurse would be most concerned about which kind of spinal cord injury? Hyperextension Axial loading Rotational Hyperflexion A client has a suspected ligament injury to the spinal vertebrae. The nurse would prepare this client for which diagnostic test? Somatosensory-evoked potentials (SEPs) MRI CT scan Lateral x-ray Which interventions are contraindicated in the care of a client in a halo vest? Select all that apply. Using the vest's struts to help pull the client up in bed Turning the client every 2 hours Removing the vest for daily hygiene and bathing Inspecting the pins for security Providing pin care as per unit protocol A nurse manager is explaining autonomic dysreflexia to a nurse who has recently transferred to the ICU. Which statement would the manager evaluate as indicating this nurse has a good understanding of this disorder? It is a parasympathetic nervous system problem resulting from unopposed vasodilation. It is a cardiovascular problem produced by decreased cardiac output secondary to bradycardia. It is a spastic disorder that limits mobility. It is a vasoconstrictive problem produced by excessive sympathetic nervous system stimulation. A client is brought to the Emergency Department with a C5-6 fracture involving the posterior wall of the vertebral body and bilateral lamina. During assessment, the nurse notes the client can feel touch on the toes. Which ASIA impairment scale designation best reflects this injury? ASIA-B There is not enough information to determine this parameter. ASIA-A ASIA-C Last week a client sustained a gunshot wound that caused a T2 SCI. This morning the client has a B/P of 210/108 and a flushed face, and complains of nasal stuffiness and a headache. The nurse responds to this assessment rapidly because of the potential for it to indicate which disorder? Autonomic dysreflexia Neurogenic shock Pneumonia onset Essential hypertension A nurse documents that a client with an SCI has full strength in the left arm on initial assessment. Which actions has this nurse taken? Select all that apply. The nurse asks the client to bend at the waist and touch the floor. The nurse asks the client to move the arm with the other hand. The nurse has asked the client to move the arm on the bed. The nurse has asked the client to dangle the arm off the bed and move it. The nurse has asked the client to move the arm against the nurse's resistance. A client with an SCI is receiving methylprednisolone. Which finding would the nurse interpret as indicating a possible complication of this therapy? The client reports seeing halos around lights. The client's stools are positive for blood. The client complains of a metallic taste. The client's urine specific gravity is increased.