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SCI & MS NCLEX Style Practice Exam Questions with 100% Correct Answers Which of the following is the priority nursing diagnosis for a patient diagnosed with a spinal cord injury? 1. Fluid Volume Deficit 2. Impaired Physical Mobility 3. Ineffective Airway Clearance 4. Altered Tissue Perfusion...

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  • October 23, 2024
  • 31
  • 2024/2025
  • Exam (elaborations)
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©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

SCI & MS NCLEX Style Practice Exam

Questions with 100% Correct Answers


Which of the following is the priority nursing diagnosis for a patient

diagnosed with a spinal cord injury?

1. Fluid Volume Deficit

2. Impaired Physical Mobility

3. Ineffective Airway Clearance

4. Altered Tissue Perfusion - ✔✔Correct Answer: 3

Rationale: Ineffective Airway Clearance is the priority nursing diagnosis for

this patient. The nurse utilizes the ABCs (airway, breathing, circulation) to

determine priority. With Ineffective Airway Clearance, the patient is at risk

for aspiration and therefore, impaired gas exchange. Fluid Volume Deficit is

the nurse's next priority (circulation), and then Altered Tissue Perfusion. If

the patient does not have enough volume to circulate, then tissue perfusion

cannot be adequately addressed. The last priority for this patient is

Impaired Physical Mobility.

,©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

A patient with a spinal cord injury at the T1 level complains of a severe

headache and an "anxious feeling." Which is the most appropriate initial

reaction by the nurse?

1. Try to calm the patient and make the environment soothing.

2. Assess for a full bladder.

3. Notify the healthcare provider.

4. Prepare the patient for diagnostic radiography. - ✔✔Correct Answer: 2

Rationale: Autonomic dysreflexia occurs in patients with injury at level T6 or

higher, and is a life-threatening situation that will require immediate

intervention or the patient will die. The most common cause is an

overextended bladder or bowel. Symptoms include hypertension,

headache, diaphoresis, bradycardia, visual changes, anxiety, and nausea.

A calm, soothing environment is fine, though not what the patient needs in

this case. The nurse should recognize this as an emergency and proceed

accordingly. Once the assessment has been completed, the findings will

need to be communicated to the healthcare provider.

A school nurse is called after a student falls down a flight of stairs. The

student is breathing, but unconsciousness. After calling the ambulance,

which is the most appropriate action by the nurse?

,©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

1. Protect the patient's neck and head from any movement.

2. Place the patient on his side to prevent aspiration.

3. Immobilize the neck,,securing the head.

4. Try to rouse the patient by gently shaking his shoulders. - ✔✔Correct

Answer: 3

Rationale: Guidelines for emergency care are avoiding flexing, extending,

or rotating the neck; immobilizing the neck; securing the head; maintaining

the patient in the supine position; and transferring from the stretcher with

backboard in place to the hospital bed. This patient is unconscious, and the

nurse must protect the neck from any (or any further) damage. If the patient

vomits, the nurse should utilize the log-roll technique to turn the patient

while keeping the head, neck, and spine in alignment. Rousing the patient

by shaking could cause damage to the spinal cord.

A hospitalized patient with a C7 cord injury begins to yell "I can't feel my

legs anymore." Which is the most appropriate action by the nurse?

1. Remind the patient of her injury and try to comfort her.

2. Call the healthcare provider and get an order for radiologic evaluation.

3. Prepare the patient for surgery, as her condition is worsening.

, ©JOSHCLAY 2024/2025. YEAR PUBLISHED 2024.

4. Explain to the patient that this could be a common, temporary problem. -

✔✔Correct Answer: 4

Rationale: Spinal shock is a condition almost half the people with acute

spinal injury experience. It is characterized by a temporary loss of reflex

function below level of injury, and includes the following symptomatology:

flaccid paralysis of skeletal muscles, loss of sensation below the injury, and

possibly bowel and bladder dysfunction and loss of ability to perspire below

the injury level. In this case, the nurse should explain to the patient what is

happening.

A patient with a spinal cord injury (SCI) is admitted to the unit and placed in

traction. Which of the following actions is the nurse responsible for when

caring for this patient?

Select all that apply.

1. modifying the traction weights as needed

2. assessing the patient's skin integrity

3. applying the traction upon admission

4. administering pain medication

5. providing passive range of motion - ✔✔Correct Answer: 2,4,5

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