In which position would the nurse place a client with a spinal cord injury experiencing autonomic?

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response?
1. hemodynamic changes related to tilt table positioning
2. deteriorating myelin sheath
3. distended large intestine
4. crushed spinal cord

3

rationale:
Bowel or bladder distention causes autonomic nerve impulses to ascend via the cord to the point of injury; here the reflex is completed, and autonomic outflow causes piloerection (goose bumps), sweating, and splanchnic vasoconstriction. Splanchnic vasoconstriction causes hypertension and a pounding headache. The client being upright on a tilt table is not involved in the autonomic hyperreflexia phenomenon. The myelin sheath deteriorating is not involved in the autonomic hyperreflexia phenomenon. The spinal cord is crushed rather than severed and is not involved in the autonomic hyperreflexia phenomenon.

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?
1. bladder control
2. nutritional intake
3. quadriceps setting
4. use of aids for ambulation

1

rationale:
Because of the location of the micturition reflex center (in the sacral region of the spinal cord), bladder function may be impaired with lower spinal cord injuries. This client's ability to ingest, digest, or metabolize food is not affected; therefore nutrition is less of a problem than bladder control. Quadriceps settings require motor control, which the client does not have. Because there is no voluntary control over the lower extremities, mobility usually is accomplished through the use of a wheelchair rather than ambulation.

A client who is recuperating from a spinal cord injury at the T4 level wants to use a wheelchair. What should the nurse teach the client to do in preparation for this activity?
1. push-ups to strengthen arm muscles
2. leg lifts to prevent hip contractures
3. balancing exercises to promote equilibrium
4. quadriceps-setting exercises to maintain muscle tone

1

rationale:
Arm strength is necessary for transfers and activities of daily living and for use of crutches or a wheelchair. Equilibrium is not a problem. The client does not have neurologic control of the other activities.

A nurse plans to monitor for signs of autonomic dysreflexia in a client who sustained a spinal cord injury at the T2 level. Why is this necessary?
1. reflexes have been lost
2. there is partial transection of the cord
3. there is damage above the sixth thoracic vertebra
4. flaccid paralysis of the lower extremities has occurred

3

rationale:
The T6 level is the sympathetic visceral outflow level, and any injury above this level may result in autonomic dysreflexia. The reflex arc remains after spinal cord injury. It is important to know the level at which the injury occurs, not whether the cord is transected. Flaccid paralysis of the lower extremities is not related to autonomic dysreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

After a client is treated for a spinal cord injury, the healthcare provider informs the family that the client is a paraplegic. The family asks the nurse what this means. Which explanation should the nurse provide?
1. lower extremities are paralyzed
2. upper extremities are paralyzed
3. one side of the body is paralyzed
4. both lower and upper extremities are paralyzed

1

rationale:
Both legs and generally the lower part of the body are paralyzed in paraplegia. There is no term to describe only upper extremities affected; all parts below an injury are affected. One side of the body paralyzed describes hemiplegia. The paralysis of both lower and upper extremities describes quadriplegia.

A young adult client is hospitalized with a spinal cord injury. The client, knowing that the paralysis may be permanent, says, "I wish God would end my suffering and take me." What is the most therapeutic initial response by the nurse?
1. you shouldnt give up hope
2. being incapacitated is difficult for you
3. would you like to speak to a religious advisor
4. have you talked to your family about your feelings

2

rationale:
The response "Being incapacitated is difficult for you" is an open-ended, accepting response that permits and encourages the client to continue to express feelings. The response "You shouldn't give up hope" rejects the client's feelings and implies that it is wrong to feel this way. The response "Would you like to speak to a religious advisor?" avoids the issue and attempts to refer discussion of the client's feelings to someone else. The response "Have you talked to your family about your feelings?" changes the focus from the client's feelings to the family's role.

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem?
1. dehydration
2. skin breakdown
3. electrolyte imbalances
4. urinary tract infections

4

rationale:
Clients in the early stages of spinal cord damage experience an atonic bladder, which is characterized by the absence of muscle tone, an enlarged capacity, no feeling of discomfort with distention, and overflow with a large residual. This leads to urinary stasis and infection. High fluid intake limits urinary stasis and infection by diluting the urine and increasing urinary output. Dehydration is not a major problem after spinal cord injury. Pressure-relieving devices and position changes are most essential in preventing skin breakdown. An electrolyte imbalance is not a major problem after spinal cord injury.

Which responses should alert the nurse that a client with a spinal cord injury is developing autonomic dysreflexia?
1. flaccid paralysis and numbness
2. absence of sweating and pyrexia
3. escalating tachycardia and shock
4. paroxysmal hypertension and bradycardia

4

rationale:
When autonomic dysreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not to dysreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs. Bradycardia occurs. These clinical findings occur as a result of exaggerated autonomic responses.

A client who sustained a spinal cord injury experienced an episode of autonomic dysreflexia. Which intervention should the nurse perform first?
1. assess for the cause
2. place the client in sitting position
3. check the client for fecal impaction
4. give an alpha blocker prophylactically

2

rationale:
Clients experiencing autonomic dysreflexia should immediately be placed in a sitting position because the condition may cause involuntary nervous system reaction and dangerous spikes in blood pressure. The next step is to assess for the cause for autonomic dysreflexia. Fecal impaction and other colorectal complications are routinely assessed in the client. Alpha blockers can be given to treat recurrent autonomic dysreflexia.

The nurse is providing care to a client with a neck and spinal cord injury. Which is the priority when moving this client during the assessment process?
1. Removing the cervical spine collar
2. Monitoring for autonomic dysreflexia
3. Implementing the logrolling technique
4. Administering the prescribed pain medication

3

rationale:
The priority when moving a client who presents with a neck and a spinal cord injury is to logroll the client whenever a transfer must occur. The nurse would not remove the cervical spine collar because this can exacerbate the original injury. The nurse would not monitor for autonomic dysreflexia during the acute phase of the injury. While monitoring and addressing pain is important, this is not the priority when transferring this client.

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation?
1. place in a sitting position
2. give nifedipine as prescribed
3. examine for symptoms of pressure ulcers
4. monitor blood pressure every 10-15 minutes

1

rationale:
Clients with spinal cord injuries are at an increased risk for developing autonomic dysreflexia. Autonomic dysreflexia is a condition in which the client has very high blood pressure. The first step in this situation is to assist the client into a sitting position because it naturally reduces blood pressure. The nurse can give nifedipine as prescribed, but only after assisting the client into a sitting position. The nurse can examine the symptoms of pressure ulcers after stabilizing the client. The nurse should monitor client's blood pressure every 10 to 15 minutes after stabilizing the client.

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?
1. Inhibiting urinary tract infections
2. Preventing contractures and atrophy
3. Avoiding flexion or hyperextension of the spine
4. Preparing the client for vocational rehabilitation

3

rationale:
The priority of care at this time is to protect the spine from additional damage to the traumatized area while it heals. Infection can result from prolonged immobility; although important, it is not the immediate priority. Although important, preventing contractures and atrophy is not the priority in the immediate postinjury period. Vocational rehabilitation will assume greater importance after the client's condition stabilizes.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment?
1. The injury results in loss of the reflex arc.
2. The injury is above the sixth thoracic vertebra.
3. There has been a partial transection of the cord.
4. There is a flaccid paralysis of the lower extremities.

2

rationale:
The T6 level is the sympathetic visceral outflow level. Because the client's injury is above this level (T2), autonomic hyperreflexia is expected. The reflex arc remains intact after spinal cord injury. The important point is not that the cord is transected, but the level at which the injury occurred. A flaccid paralysis of the lower extremities is not related to autonomic hyperreflexia. All cord injuries result in flaccid paralysis during the period of spinal shock; as the inflammation subsides, spasticity gradually increases.

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?
1. hypertension and bradycardia
2. flaccid paralysis and numbness
3. absence of sweating and pyrexia
4. escalating tachycardia and shock

1

rationale:
Hypertension and bradycardia occur as a result of exaggerated autonomic responses. If autonomic hyperreflexia is identified, immediate intervention is necessary to prevent serious complications. Paralysis is related to transection, not autonomic hyperreflexia; the client will have no sensation below the injury. Profuse diaphoresis occurs above the level of injury. Bradycardia occurs.

A young man who sustained a spinal cord injury at the cervical level expresses concern about sexual functioning. What should the nurse do when counseling this client?
1. Consider that the client most likely will be able to have reflex penile erections.
2. Arrange for the client to see the healthcare provider because sexual performance is unlikely.
3. Discourage the client from forming sexual relationships because little pleasure will be possible.
4. Reassure the client that he will be able to have sexual relationships with the ability to reproduce.

1

rationale:
The reflex arc for sexual activity is intact; control of ejaculation is not. The ability to perform sexually is determined on an individual basis. There are many ways to fulfill sexual needs. Reassuring the client that he will be able to have sexual relationships with the ability to reproduce may provide false reassurance. The ability to function is determined on an individual basis.

A nurse is caring for a client with a spinal cord injury. What is the specific reason fluid intake should be increased for this client?
1. to prevent dehydration
2. to maintain electrolyte balance
3. to prevent a urinary tract infection
4. to limit an increase in temperature

3

rationale:
Lack of or reduced movement predisposes the client with paraplegia or quadriplegia to urinary stasis, which may result in a urinary tract infection and calculus formation. All individuals require fluid to prevent dehydration; this is not why fluids are encouraged for this client. Administration of fluids does not maintain electrolyte balance. Fluids do not prevent an increase in temperature.

The nurse is caring for a client one week after the client experienced a spinal cord injury at the T3 level. What is an appropriate short-term goal for this client?
1. the client will understand limitations
2. the client will consider lifestyle changes
3. the client will perform independent ambulation
4. the client will carry out personal hygiene activities

4

rationale:
If the client has the capability to perform personal hygiene activities, it will help maintain a positive identity. Understanding limitations, considering lifestyle changes, and performing independent ambulation are necessary for progression to long-term goals.

The nurse is caring for a client in active labor with a history of T5 spinal cord injury. Which of the following findings indicates to the nurse that the client is experiencing a complication of the labor process?
1. increased pulse rate
2. increased urine output
3. increased blood pressure
4. flaccidity in the lower extremities

3

rationale:
A client with a spinal cord injury at T6 or higher is at risk for autonomic dysreflexia, marked by increased blood pressure and bradycardia. The nurse will need to carefully monitor this client throughout the labor process. An increased pulse rate may be a result of the adaptation of the labor process. Increased urine output would be expected, because clients are well hydrated in labor; this does not indicate a complication. Flaccidity is an expected assessment finding for a client with this history.

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?
1. Placing the child's head on a pillow for support
2. Immobilizing the child's spine to limit additional injury
3. Log-rolling the child to check for lacerations on the back
4. Moving the child onto a firm stretcher for transport to the radiography department

2

rationale:
Immobilization of the spine is most important to minimize additional injury while the child is being assessed. Placing a pillow under the head is contraindicated because the vertebral column and spinal cord might move, resulting in additional damage to the spinal cord. Log-rolling is unsafe without prior immobilization of the spine, as is moving the child.

A preschool child with a spinal cord injury will be on prolonged bed rest. The nurse explains to the parents that certain foods will be restricted to prevent complications associated with immobility. What food should be noted as restricted in the teaching plan?
1. fish
2. fruit
3. beef
4. cheese

4

rationale:
Cheese contains calcium, which is excreted by the kidneys and may contribute to the formation of kidney stones; it adds to the child's risk because immobility causes bone decalcification. Fish contains protein, which is needed for wound healing and growth. Fruit contains some fiber, which will help decrease the risk of constipation. Beef contains protein, which is needed for wound healing and growth.

A young adult sustained a spinal cord injury at the level of T5 a week ago and is now incontinent of feces. When the nurse tries to give a bath and change the linens, the client says, "Leave me alone. It's worse having you change me than it is to lie in this mess." What is the best response by the nurse?
1. "Do you want me to get someone else to change you?"
2. "You shouldn't be embarrassed; this is part of my job."
3. "I'll be back in a little while; why don't you rest until then?"
4. "While I'm bathing you I'll start teaching you about bowel training."

4

rationale:
A matter-of-fact approach eases embarrassment and then focuses on a method of helping the client regain control. The response "Do you want me to get someone else to change you?" ignores the issue, and with it the nurse is abandoning responsibility. The response "You shouldn't be embarrassed; this is part of my job" lacks empathy and does not offer hope for improvement. The response "I'll be back in a little while; why don't you rest until then?" cuts off communication and ignores the client's need to be changed.

A client was admitted to the hospital with a direct injury to the vertebral column from a gunshot after a mass shooting. The nurse suspects a spinal cord injury. Which mechanism of injury might be the reason for the injury?
1. hyperflexion
2. hyperextension
3. excessive rotation
4. penetrating trauma

4

rationale:
The mechanism of penetrating trauma is involved when an injury occurs due to piercing, which is classified by the velocity of the piercing vehicle such as a bullet. A hyperflexion injury happens when extreme flexion of the neck occurs due to a sudden and forceful forward acceleration of the head. Hyperextension occurs when the head is suddenly accelerated and then decelerated or during a fall if the client's chin is struck. When the head is rotated or turned beyond the normal range, excessive rotation injury occurs.

The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately?
1. monitoring urinary output
2. assessing for other injuries
3. infusing lactated Ringer solution
4. immobilizing and stabilizing cervical spine

4

rationale:
A client with a spinal cord injury should first have the cervical spine immobilized and stabilized. Monitoring urinary output should be performed during ongoing assessments, after providing initial treatment. The client should be assessed for other injuries after immediate interventions are performed. Ringer solution should be infused after stabilizing oxygen levels and cervical spine.

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?
1. A
2. B
3. C
4. D

4

rationale:
The sacrum, letter D, bears the most pressure because it is the focal point of the weight of the body when in the low Fowler position; also, shearing forces may cause local tissue trauma. Although other areas of the body are vulnerable, they do not bear as much body weight as the sacrum when the client is in the low Fowler position.

A nurse is caring for a client who has paraplegia as a result of a spinal cord injury. Which rehabilitation plan will be most effective for this client?
1. Arrangements will be made by the client and the client's family.
2. The plan is formulated and implemented early in the client's care.
3. The rehabilitation is minimal and short term, because the client will return to former activities.
4. Arrangements will be made for long-term care, because the client is no longer capable of self-care.

2

rationale:
To promote optimism and facilitate smooth functioning, rehabilitation planning should begin on admission to the hospital. The client and family often are unaware of the options available in the healthcare system; the nurse should be available to provide the necessary information and support. Rehabilitation helps a client adjust to a new lifestyle that must compensate for the paralysis. The goal of rehabilitation is to foster independence wherever the client may live after discharge.

A nurse provides discharge teaching related to intermittent urinary self-catheterization to a client with a new spinal cord injury. Which instruction is most important for the nurse to include?
1. "Wear sterile gloves when doing the procedure."
2. "Wash your hands before performing the procedure."
3. "Perform the self-catheterization every 12 hours."
4. "Dispose of the catheter after you have catheterized yourself."

2

rationale:
To prevent transferring organisms to the urinary system, the client is taught to wash his or her hands thoroughly with soap and water before inserting a clean catheter. Sterile gloves are not required for this procedure in the home care setting. Every 12 hours is too long of a time frame between catheterizations. The client should be taught to recognize when self-catheterization is needed and develop a 2- to 3-hour catheterization schedule. Some home care settings may require the client to clean and re-use catheters.

A client who was in a traffic accident is choking. The nurse suspects that the client may have a spinal cord injury. Which procedure may benefit the client?
1. Performing vagal maneuver
2. Performing Valsalva maneuver
3. Performing jaw-thrust maneuver
4. Performing oculocephalic maneuver

3

rationale:
Road traffic accidents and other traumas can cause an airway occlusion. Therefore it may be necessary to ensure a patent airway by opening the jaw with a jaw-thrust maneuver. This helps to clear the airway. The nurse should also protect the cervical spine by manually aligning the neck in a neutral, in-line position. The vagal maneuver induces vagal nerve stimulation to slow cardiac conduction. The Valsalva maneuver involves breath holding, bearing down for bowel movements, and coughing to prevent cardiac problems. Oculocephalic maneuvers are performed to assess whether brainstem eye movement pathways are intact.

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.
1. bradycardia
2. hypotension
3. spastic paralysis
4. bladder dysfunction
5. increased pulse pressure

1, 2, 4

rationale:
Bradycardia occurs with spinal shock because the vascular system below the level of injury dilates and the cardiac accelerator reflex is suppressed. Initially there is a loss of vascular tone below the injury, resulting in hypotension. Bladder dysfunction in the form of urinary retention or oliguria may occur in spinal shock. Initially, flaccid paralysis is associated with spinal shock; as spinal shock subsides, spastic paralysis develops. There is a decreased, not increased, pulse pressure associated with hypotension and shock.

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action?
1. Change the client's diet to bland.
2. Obtain a stool specimen for occult blood.
3. Prepare for insertion of a nasogastric tube.
4. Monitor recent laboratory reports for hemoglobin levels.

3

rationale:
The client should have a nasogastric tube inserted to keep the stomach decompressed; the nurse should monitor the amount and characteristics of the drainage. Coffee-ground gastric fluid indicates blood that has been influenced by gastric juices. The healthcare provider should be notified. Changing the client's diet to bland is unsafe; the client needs immediate medical attention. Obtaining a stool specimen for occult blood is indicated at the next bowel movement, but it is not the priority. Monitoring recent laboratory reports for hemoglobin levels is unsafe; the client needs immediate medical attention.

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply.
1. spasticity
2. incontinence
3. flaccid paralysis
4. respiratory failure
5. lack of reflexes below the injury

3, 5

rationale:
Spinal shock (spinal shock syndrome) is immediate after a transection of the spinal cord; it results in flaccid paralysis of all skeletal muscles and usually lasts for 48 hours, but may persist for several weeks. Spinal shock is caused by transection of the spinal cord and results in a loss of reflex activity below the level of the injury. Spasticity occurs after spinal shock has subsided. During the acute phase, retention of urine and feces occurs as a result of decreased tone of the bladder and bowel; thus, incontinence is unusual. Respirations are labored, but spontaneous breathing continues, indicating that the level of injury is below C4 and respirations are not affected.

What is the best position for a patient experiencing autonomic dysreflexia?

Which position would the nurse place a client in after a recent stroke?

Which of the following clients is at highest risk for autonomic dysreflexia?

Which are characteristics of autonomic dysreflexia?