CNRN Traumatic Brain Injury and Spinal Cord Injury 2

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:

Accepted Answer

Autonomic dysreflexia

Answer

Ischemic stroke

Answer

Orthostatic hypotension

Answer

Pulmonary embolism

Question 2

The nurse's FIRST action when autonomic dysreflexia is suspected is to:

Accepted Answer

Sit the patient upright and search for the precipitating stimulus

Answer

Administer IV labetalol immediately

Answer

Place the patient in Trendelenburg position

Answer

Administer sublingual nitroglycerin

Question 3

Which spinal cord injury level results in a patient who is ventilator-dependent due to loss of diaphragm function?

Accepted Answer

C3 and above

Answer

T1–T4

Answer

C5–C6

Answer

C7–T1

Question 4

The ASIA Impairment Scale (AIS) Grade A for spinal cord injury means:

Accepted Answer

Complete injury with no motor or sensory function below the neurological level

Answer

Normal motor and sensory function

Answer

Incomplete injury with sensory but no motor function below the level

Answer

Incomplete injury with normal motor function

Question 5

Which complication of spinal cord injury is the LEADING cause of death in the chronic phase?

Accepted Answer

Urinary tract infections and urosepsis

Answer

Pressure injuries

Answer

Deep vein thrombosis

Answer

Respiratory complications

Question 6

A patient with acute cervical SCI is maintained in cervical traction using Gardner-Wells tongs. The nurse's priority assessment is:

Accepted Answer

Pin site inspection for loosening or infection

Answer

Daily CBC for blood loss

Answer

Hourly blood pressure for orthostatic changes

Answer

Respiratory rate only