NUR 213: Spinal Cord Injury Questions With Complete
Solutions
A client with a cervical injury reports the sudden onset of a
severe headache and nasal congestion. For which clinical
manifestations would the nurse assess?
1. Suprapubic distention
2. Increased spinal reflexes
3. Adventitious breath sounds
4. Imminent development of shock Correct Answer 1.
Suprapubic distention
Suprapubic distention is a symptom of autonomic dysreflexia,
which is commonly precipitated by a distended bladder. Blood
pressure increases suddenly with AE causing the severe
headache and nasal congestion.
A pediatric client is prescribed an intravenous infusion of
methylprednisolone. Which clinical manifestation requires
immediate intervention during administration of the initial dose.
1. Polyuria
2. Tinnitus
3. Drowsiness
4. Hypotension Correct Answer 1. Polyuria
Intravenous administration of a steroid can cause a rapid
increase in the blood glucose level. One early sign of
hyperglycemia is increased urine output. Blood glucose should
be checked frequently, and insulin administered as needed.
, Autonomic Dysreflexia Correct Answer - It is a MEDICAL
EMERGENCY (can lead to stroke or seizure)
- Happens if SCI is T6 or higher
- Happens when irritating stimulus occurs below the site of
spinal injury
- Can cause high BP (vasoconstriction below level of injury),
flushing (vasodilation above level of injury), low HR
(parasympathetic NS response), headache, blurred vision,
sweating, goosebumps
- Priority action: Sit patient up or raise head of bed to High
Fowlers to relieve pressure and lower BP
- Other actions: loosen restrictive clothing, check for fecal
impaction, urinary retention, and skin integrity
- Meds: antihypertensives
Bloating and abdominal distention Correct Answer - may need
to decompress using NG tube
- NG tube use may lead to metabolic alkalosis (monitor
electrolytes, may need IV nutritional supplements)
C1 - C8 spinal nerves (Cervical) Correct Answer Neck,
shoulder, upper arms, diaphragm (patient may need ventilator)
Causes of spinal cord injury Correct Answer - vehicle crashes
- falls
- violence
- sports
- happens more in men
Complete vs. Incomplete Correct Answer Complete: no
function below the injury
Solutions
A client with a cervical injury reports the sudden onset of a
severe headache and nasal congestion. For which clinical
manifestations would the nurse assess?
1. Suprapubic distention
2. Increased spinal reflexes
3. Adventitious breath sounds
4. Imminent development of shock Correct Answer 1.
Suprapubic distention
Suprapubic distention is a symptom of autonomic dysreflexia,
which is commonly precipitated by a distended bladder. Blood
pressure increases suddenly with AE causing the severe
headache and nasal congestion.
A pediatric client is prescribed an intravenous infusion of
methylprednisolone. Which clinical manifestation requires
immediate intervention during administration of the initial dose.
1. Polyuria
2. Tinnitus
3. Drowsiness
4. Hypotension Correct Answer 1. Polyuria
Intravenous administration of a steroid can cause a rapid
increase in the blood glucose level. One early sign of
hyperglycemia is increased urine output. Blood glucose should
be checked frequently, and insulin administered as needed.
, Autonomic Dysreflexia Correct Answer - It is a MEDICAL
EMERGENCY (can lead to stroke or seizure)
- Happens if SCI is T6 or higher
- Happens when irritating stimulus occurs below the site of
spinal injury
- Can cause high BP (vasoconstriction below level of injury),
flushing (vasodilation above level of injury), low HR
(parasympathetic NS response), headache, blurred vision,
sweating, goosebumps
- Priority action: Sit patient up or raise head of bed to High
Fowlers to relieve pressure and lower BP
- Other actions: loosen restrictive clothing, check for fecal
impaction, urinary retention, and skin integrity
- Meds: antihypertensives
Bloating and abdominal distention Correct Answer - may need
to decompress using NG tube
- NG tube use may lead to metabolic alkalosis (monitor
electrolytes, may need IV nutritional supplements)
C1 - C8 spinal nerves (Cervical) Correct Answer Neck,
shoulder, upper arms, diaphragm (patient may need ventilator)
Causes of spinal cord injury Correct Answer - vehicle crashes
- falls
- violence
- sports
- happens more in men
Complete vs. Incomplete Correct Answer Complete: no
function below the injury
