A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Autonomic dysreflexia

Ischemia

Edema

Axial loading

Hemorrhage

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is ["B","C","D"]

Explanation

Choice A reason:

Applying tight-fitting clothing is not recommended for patients at risk of autonomic dysreflexia. Tight clothing can be a trigger for this condition by causing discomfort and potentially leading to an exaggerated autonomic response.

Choice B reason:

Completing frequent skin checks is crucial in preventing autonomic dysreflexia. Skin irritation, pressure sores, and other integumentary issues can trigger autonomic responses. Regular assessments help in early identification and prevention of potential irritants.

Choice C reason:

Initiating a bowel regimen program is essential for preventing autonomic dysreflexia. Constipation or bowel distension can be potent triggers for this condition. A consistent bowel program helps in managing and preventing these issues.

Choice D reason:

Inserting an indwelling Foley catheter is recommended to manage bladder distention, a common trigger of autonomic dysreflexia. Continuous bladder drainage prevents overdistention and reduces the risk of triggering autonomic responses.

Choice E reason:

Restricting all patient visitors is unnecessary for preventing autonomic dysreflexia. While a calm environment can be beneficial, visitor restriction is not directly related to managing the risk of this specific condition.

A. Increased oxygen saturation. B. Urine output less than 30 mL/hr. C. Decreased level of consciousness. D. Heart rate of 34 beats/min.

Correct Answer is ["B","D"]

Explanation

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders:

Correct Answer is ["B","C","D"]

Explanation

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Correct Answer is ["B","D"]

Explanation

A patient presents to the emergency department with signs of an epidural hematoma. Which manifestation is characteristic of this type of hematoma?

A nurse is caring for a patient who has a closed-head injury with ICP readings ranging from 16-22 mm Hg. What actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply.

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

When planning care for a patient on a mechanical ventilator, the nurse understands that the application of positive end-expiratory pressure (PEEP) to the ventilator settings has which therapeutic effect?

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?