An unconscious patient receiving emergency care following an automobile crash accident has a possible spinal cord injury. What guidelines for emergency care should be followed?
Select all that apply.
1. Immobilize the patient's neck using rolled towels or a cervical collar.
2. Place the patient in a supine position
3. Place the patient on a ventilator.
4. Elevate the head of the bed.
5. Secure the patient's head with a belt or tape secured to the stretcher.
Question 2A patient with a secondary metastatic spinal cord tumor is scheduled for surgery. What should the nurse recognize as the goal of surgery for this patient?
1. complete removal of the tumor and affected spinal cord tissue
2. eradication of the tumor with excision and drainage
3. tumor excision to reduce cord compression
4. exploration to visualize the tumor and obtain a biopsy
Question 3A patient is admitted with injuries sustained in a fall. During the nurse's first assessment upon admission, the findings are: blood pressure 90/60 (as compared to 136/66 in the emergency department), flaccid paralysis on the right,
absent bowel sounds, zero urine output, and palpation of a distended bladder. The nurse realizes that these findings are consistent with which condition?
1. paralysis
2. spinal shock
3. high cervical injury
4. temporary hypovolemia
Question 4A patient with a spinal cord injury (SCI) has complete paralysis of both upper and lower extremities. Which term should the nurse use when documenting this patient's status?
1. hemiplegia
2. paresthesia
3. paraplegia
4. quadriplegia
Question 5A lumbar puncture (LP) is performed on a patient to rule out a spinal cord tumor. The cerebrospinal fluid (CSF) is xanthochromic, has increased protein and no cells, and clots immediately.
What syndrome should the nurse suspect this patient is experiencing?
1. Glasgow syndrome
2. Froin syndrome
3. cord tumor syndrome
4. reflex syndrome
Question 6The nurse understands that when the spinal cord is injured, ischemia and edema result. How should the nurse explain to the patient the reason that the extent of injury cannot be determined for several days to a week?
1. Tissue repair does not begin for 72 hours.
2. The edema extends the level of injury two cord segments above and below the affected level.
3. Neurons need time to regenerate, so stating the extent of injury early is not predictive of how the patient progresses.
4. Necrosis of gray and white matter does not occur until days after the injury.
Question 7While caring for a patient with a spinal cord injury (SCI), the nurse elevates the head of the bed, removes compression stockings,
and continues to assess vital signs every 2 to 3 minutes while searching for the cause in order to prevent loss of consciousness or death. By practicing these interventions, the nurse is avoiding the most dangerous complication of autonomic dysreflexia, which is what condition?
1. hypoxia
2. bradycardia
3. elevated blood pressure
4. tachycardia
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