CNRN Traumatic Brain Injury and Spinal Cord Injury 2 — Questions and Answers
Question 1: A patient with a C5 spinal cord injury develops sudden severe headache, sweating above the level of injury, hypertension, and bradycardia. The nurse immediately suspects:
- Ischemic stroke
- Autonomic dysreflexia (Correct answer)
- Orthostatic hypotension
- Pulmonary embolism
Correct answer: Autonomic dysreflexia
Autonomic dysreflexia is a life-threatening syndrome in patients with SCI at T6 or above, triggered by noxious stimuli below the injury level causing uncontrolled hypertension.
Question 2: The nurse's FIRST action when autonomic dysreflexia is suspected is to:
- Administer IV labetalol immediately
- Sit the patient upright and search for the precipitating stimulus (Correct answer)
- Place the patient in Trendelenburg position
- Administer sublingual nitroglycerin
Correct answer: Sit the patient upright and search for the precipitating stimulus
Sitting the patient upright to lower BP and immediately identifying and removing the precipitating noxious stimulus (e.g., full bladder, fecal impaction) is the first priority in autonomic dysreflexia.
Question 3: Which spinal cord injury level results in a patient who is ventilator-dependent due to loss of diaphragm function?
- T1–T4
- C3 and above (Correct answer)
- C5–C6
- C7–T1
Correct answer: C3 and above
The phrenic nerve (C3, C4, C5 — 'keeps the diaphragm alive') originates at C3–C5; injury at C3 or above disrupts diaphragmatic function, requiring ventilatory support.
Question 4: The ASIA Impairment Scale (AIS) Grade A for spinal cord injury means:
- Normal motor and sensory function
- Incomplete injury with sensory but no motor function below the level
- Complete injury with no motor or sensory function below the neurological level (Correct answer)
- Incomplete injury with normal motor function
Correct answer: Complete injury with no motor or sensory function below the neurological level
ASIA Impairment Scale Grade A indicates a complete spinal cord injury with no preserved motor or sensory function in the sacral segments S4–S5.
Question 5: Which complication of spinal cord injury is the LEADING cause of death in the chronic phase?
- Pressure injuries
- Urinary tract infections and urosepsis (Correct answer)
- Deep vein thrombosis
- Respiratory complications
Correct answer: Urinary tract infections and urosepsis
Urinary tract infections progressing to urosepsis are the leading cause of death in the chronic phase of spinal cord injury due to neurogenic bladder dysfunction.
Question 6: A patient with acute cervical SCI is maintained in cervical traction using Gardner-Wells tongs. The nurse's priority assessment is:
- Pin site inspection for loosening or infection (Correct answer)
- Daily CBC for blood loss
- Hourly blood pressure for orthostatic changes
- Respiratory rate only
Correct answer: Pin site inspection for loosening or infection
Monitoring pin sites for signs of infection, loosening, or skin breakdown is the priority nursing assessment for patients in cervical traction devices.
CNRN Traumatic Brain Injury and Spinal Cord Injury 2
A patient with a C5 spinal cord injury develops sudden severe headache, sweating above the level of injury, hypertension, and bradycardia.
The nurse immediately suspects: