SOLVED

 Question 11 A patient is admitted with a spinal cord injury located at the 4th thoracic vertebral area. When assessing this patient, the nurse will expect to find sensory deficits at which anatomical area? 1. Anterior thigh 2. Nipple line 3. Umbilicus 4. Groin Question 12 A patient is diagnosed with a spinal cord injury located at the 1st and 2nd thoracic vertebra. The nurse will expect to find which deep tendon reflexes affected by this injury? 1. Supinator 2. Patellar 3. Triceps 4. Biceps 5. Achilles Question 13 A patient diagnosed with several fractured vertebra is having surgical stabilization. The nurse would reinforce which information about this surgery? 1. “You will be required to wear a hard cervical collar for several months after the surgery.” 2. “After surgery you will be fitted for a halo device.” 3. “The fusion generally requires insertion of rods to stabilize your spine internally.” 4. “This is the first of a series of surgeries you will require.” Question 14 What interventions will the nurse include in the plan of care for a patient with a newly applied halo device and vest? 1. Assess motor and sensory function every shift. 2. Have the patient hold onto the halo struts during turns and repositioning. 3. Keep the pins and traction bars slightly loose to prevent pressure ulcers. 4. Tape a halo vest wrench to the front of the vest. 5. Use a moist cloth to clean the skin under the vest. Question 15 A patient recovering from surgery to stabilize a lumbar spinal cord injury is fitted with a clam shell brace. How would the nurse explain the purpose of this brace? 1. “Wearing this brace will eliminate the need for further surgery.” 2. “You need to wear this device to support your surgical site.” 3. “This brace will maximize your range of motion.” 4. “You need to wear this brace to protect your surgical incision.” Question 16 A patient who injured his cervical spine was first taken to the emergency department of a small hospital where methylprednisolone (MPSS) was started intravenously. The patient has now been transferred to a neurointensive care unit in a large hospital. What interventions would the nurse in the receiving agency include in the plan of care? 1. Assess the patient’s breath sounds every 2 hours. 2. Check all stools for blood. 3. Keep the patient NPO. 4. Insert an indwelling urinary catheter so accurate intake and output can be measured. 5. Monitor for the development of hypotension. Question 17 A patient has a spinal cord injury at C6–T1. During his bath the nurse notes piloerection. What nursing interventions are indicated? 1. Ask the patient about the presence of a headache. 2. Ignore the occurrence and continue with the bath. 3. Determine if the patient’s indwelling urinary catheter tubing is twisted. 4. Lower the head of the patient’s bed. 5. Cover the exposed portions of the patient’s body with a warm bath blanket. Question 18 A patient is admitted with a possible 2nd cervical vertebra injury. The nurse prepares for which most likely method to manage the patient’s respiratory system? 1. Incentive spirometer every hour while awake. 2. Quad coughing 3. Humidified oxygen via face mask 4. Intubation and mechanical ventilation Question 19 A patient in the intensive care unit with a spinal cord injury is receiving intravenous fluid therapy for hypotension. Which finding would the nurse evaluate as indicating the therapy has had its desired effect? 1. Normal temperature 2. Systolic blood pressure of 85 mm Hg 3. Systolic blood pressure of 120 mm Hg 4. Mean arterial pressure of 88 Hg Question 20 The nurse is helping a patient who is recovering from a 2nd to 4th thoracic vertebral injury with transferring from bed to sitting in a chair. Which nursing interventions are indicated to prevent the onset of orthostatic hypotension? 1. Apply a binder around the patient’s abdomen. 2. Be certain the patient is wearing compression stockings. 3. Swing the patient’s legs to the side of the bed in one swift, smooth movement. 4. Gradually raise the head of the bed. 5. Allow the patient to sit on the side of the bed with feet dangling before moving to a chair.