[Osborn] chapter 32

Learning Outcomes [Number and Title ]

Learning Outcome 1
Compare and contrast the most common causes of acute spinal
cord injury in persons under the age of 65 as opposed to
persons over the age of 65.
Learning Outcome 2
Differentiate between a complete and an incomplete spinal cord
injury.
Learning Outcome 3
Explain three complications of spinal cord injury and strategies
to prevent these complications.
Learning Outcome 4
Discuss the psychosocial impact of spinal cord injury on the
patient and family.
Learning Outcome 5
Identify rehabilitative needs and goals for discharge for the
patient who has experienced a spinal cord injury.
Learning Outcome 6
Select three nursing diagnoses and apply the nursing process in
the care of the patient who has experienced a spinal cord injury.

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

1. A nurse recognizes that an example of a major source of spinal cord injuries (SCIs) in
persons aged 30 years and younger is a:
1.
2.
3.
4.

Motorcycle accident.
Fall down a flight of stairs.
Diving accident.
Schwannomas tumor.

Correct Answer: Motorcycle accident.

Rationale: The vast majority of SCIs are the result of a traumatic event. The most
common cause of SCIs in persons under the age of 65 is motor vehicle crashes. Falls rank
as the most common cause of SCI in people over the age of 65. Spinal cord injuries due
to nontraumatic causes are more likely to occur in persons older than 40 years of age.
Schwannomas tumors are seen most commonly in women over the age of 40.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

2. In a community education presentation, a nurse should plan to include which of the

following as factors that contribute to the heightened risk for spinal cord injuries (SCI) in
the older adult population?
Select all that apply.
1.
2.
3.
4.
5.

Hypertrophy of spinal ligaments

Bone spurs on the spinal column
Osteoporosis of the vertebra
Diabetes mellitus
Cardiac induced syncope

Correct Answer:
1. Hypertrophy of spinal ligaments
2. Bone spurs on the spinal column
3. Osteoporosis of the vertebra
Rationale: Hypertrophy of spinal ligaments. The elderly are at increased risk of injury
to the spinal cord because of degenerative changes in the spinal column, including
ossification and hypertrophy of the spinal ligaments. Bone spurs on the spinal column.
The elderly are at increased risk of injury to the spinal cord because of degenerative
changes in the spinal column, including development of bone spurs within the spinal
column leading to narrowing of the spinal canal. Osteoporosis of the vertebra.
Weakening of the bone due to osteoporosis also increases the risk of spinal fracture in
these patients. Diabetes mellitus. This patient population presents an added challenge to
the management of acute SCI after it occurs because of preexisting medical problems
such as diabetes. Cardiac induced syncope. This patient population presents an added
challenge to the management of acute SCI after it occurs because of preexisting medical
problems such as heart disease, as well as the normal physiological effects of aging.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

3. When speaking to a group of teenagers regarding risky behaviors that can lead to
spinal cord injuries (SCI), the nurse should mention:
Select all that apply.
1.
2.
3.
4.
5.

Not appointing a designated driver.

Diving into unfamiliar water.
Refusing to wear a helmet while dirt-biking.
Wearing leather-soled shoes.
Forgetting to wear prescription glasses.

Correct Answer:
1. Not appointing a designated driver.
2. Diving into unfamiliar water.
3. Refusing to wear a helmet while dirt-biking.
Rationale: Not appointing a designated driver. The key to reducing the incidence of
these injuries is to decrease high-risk behaviors such as driving while under the influence
of drugs or alcohol. Diving into unfamiliar water. The key to reducing the incidence of
these injuries is to decrease high-risk behaviors such as diving into shallow water.
Refusing to wear a helmet while dirt-biking. The key to reducing the incidence of these
injuries is to decrease high-risk behaviors such as lack of seat belt and helmet use.
Wearing leather-soled shoes. Falls are more of a risk factor for the older population, so
wearing rubber-soled shoes would be more appropriate for that population. Forgetting to
wear prescription glasses. Falls are more of a risk factor for the older population, so
remembering ones glasses would be more appropriate for that population.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Health Promotion and Maintenance
LO: 1

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

4. The nursing assessment confirms that the client has experienced loss of voluntary
motor and sensory function of both upper and lower extremities, as well as bowel and
bladder control, due to a spinal cord injury (SCI). The nurse recognizes that which of the
following is true regarding this client?
Select all that apply.
1.
2.
3.
4.
5.

The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.
Tetraplegia is a term that describes these neurological deficiencies.
All deep tendon reflexes are affected.
This client has experienced an incomplete spinal injury.
The client is likely to regain only limited motor control.

Correct Answer:
1. The injury was likely a result of trauma to the C1 to C4 level of the spinal cord.
2. Tetraplegia is a term that describes these neurological deficiencies.
3. All deep tendon reflexes are affected.
Rationale: The injury was likely a result of trauma to the C1 to C4 level of the spinal
cord. An injury at this level will exhibit all of the identified symptoms. Tetraplegia is a
term that describes these neurological deficiencies. Injuries involving the cervical
spinal cord will result in tetraplegia (a Greek term; quadriplegia is the Latin term), or loss
of motor and sensory function involving both upper extremities, both lower extremities,
bowel, and bladder. All deep tendon reflexes are affected. The clients injuries would
result in deep tendon reflex involvement. This client has experienced an incomplete
spinal injury. A complete spinal cord injury indicates complete loss of voluntary motor
and sensory functions below the level of injury. The client is likely to regain only
limited motor control. The damage to the spinal cord in this type of injury is
irreversible.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

5. The nurse is caring for a client who has been diagnosed with an incomplete spinal cord
injury (SCI) that has resulted in central cord syndrome. The nurse expects that:
Select all that apply.
1.
2.
3.
4.
5.

The client has preexisting degenerative bone changes.

This is likely a result of a hyperextension injury to the cervical spine.
Function, if restored, will occur first in the hands.
Prognosis for recovery is poor.
Loss of function will be greatest in the lower extremities.

Correct Answer:
1. The client has preexisting degenerative bone changes.
2. This is likely a result of a hyperextension injury to the cervical spine.
Rationale: The client has preexisting degenerative bone changes. Central cord
syndrome is the most common incomplete SCI. This injury can occur at any age, but is
seen most frequently in older patients who have degenerative bony changes in the
cervical spine resulting in narrowing of the overall diameter of the spinal canal. This is
likely a result of a hyperextension injury to the cervical spine. It most often is caused
by a hyperextension injury resulting in damage to the center of the spinal cord. Function,
if restored, will occur first in the hands. The typical pattern of recovery is return of
lower extremity function first followed by return of bladder function. Recovery of hand
intrinsic function is variable and often the last to return. Prognosis for recovery is poor.
The overall prognosis for recovery from this injury is generally favorable. Loss of
function will be greatest in the lower extremities. There is greater loss of motor and
sensory function in the upper extremities than in the lower extremities.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

6. A client who has experienced an incomplete spinal cord injury (SCI) is most expected
to:
1.
2.
3.
4.

Experience some neurotransmission of impulses.

Have sensory function restored first.
Be subjected to only a mild motor deficiency.
Experience a good prognosis for recovery.

Correct Answer: Experience some neurotransmission of impulses.

Rationale: Patients who have experienced an incomplete spinal cord injury will have
some preservation of sensory and/or motor function below the level of injury. In these
patients, there is sparing of some of the spinal cord tracts, which allows
neurotransmission to occur. Five main syndromes are associated with incomplete SCI,
each classified according to the portion of the spinal cord damaged and the preservation
of function below the level of injury. Prognosis, restoration of function, and degree of
motor and sensory loss are specific to the resulting syndrome.
Cognitive Level: Synthesis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 2

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

7. A client with an incomplete spinal cord injury is being transferred from intensive care
to the neurological trauma unit. The nurse realizes that in order to minimize the risk of
the client developing autonomic hyperreflexia, the following interventions should be
included in the clients care plan:
Select all that apply.
1.
2.
3.
4.
5.

Bladder scan post-voiding

Strict output monitoring
Assessing for abdominal distention
Monitoring skin temperature in lower extremities
Assessing pulse oximetry levels with vitals

Correct Answer:
1. Bladder scan post-voiding
2. Strict output monitoring
3. Assessing for abdominal distention
Rationale: Bladder scan post-voiding. The nurse should be attuned to the prevention of
a distended bladder when caring for spinal cord injury (SCI) clients in order to prevent
the chain of events that leads to autonomic hyperreflexia. Scan the bladder post-voiding
to determine the presence of residual urine retention. Strict output monitoring. Track
urinary output carefully to determine the presence of residual urine retention. Assessing
for abdominal distention. Causes of autonomic hyperreflexia are impacted stool or
constipation, so assessing for abdominal distention is appropriate. Monitoring skin
temperature in lower extremities. Monitoring lower extremity skin temperature is
appropriate for detecting deep vein thrombosis. Assessing pulse oximetry levels with
vitals. Pulse oximetry is effective in monitoring for a decline in oxygen saturation and
may be the initial indicator of a pulmonary emboli.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

8. A client is admitted after a fall that has resulted in spinal shock. When asked by the
clients family how long the existing paralysis is likely to last, the nurses response is
based on the knowledge that:
1. The severity of the injuries cannot be determined until the spinal shock resolves.
2. Spinal shock is irreversible and the paralysis is likely to be permanent.
3. There will likely be some minor improvement in the degree of paralysis.
4. Spinal shock usually results in temporary paralysis.
Correct Answer: The severity of the injuries cannot be determined until the spinal shock
resolves.
Rationale: Spinal shock is a state of areflexia in which there is a loss of all motor,
sensory, and reflex activity at the level of the injury and below. Spinal shock occurs as a
result of the primary injury. The duration of spinal shock is quite variable, lasting as little
as a few hours or as long as several weeks after injury. During this state, it is impossible
to determine the extent of the SCI. At this point in time, it is not possible to determine
whether the paralysis is temporary, permanent, or will lessen.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

9. A client with a spinal cord injury is at risk for complications to the gastrointestinal
system. The nursing intervention primarily directed at minimizing this risk is:
1.
2.
3.
4.

Insertion of a nasogastric tube.

Administration of a lansoprazole (Prevacid).
Elevating the end of the bed to 35 degrees.
Regular assessment of the clients bowel sounds.

Correct Answer: Insertion of a nasogastric tube.

Rationale: Gastrointestinal effects of spinal shock include gastroparesis, loss of intestinal
peristalsis, and ileus. Placement of a nasogastric or oral gastric tube will be necessary in
the acute phase of SCI for decompression of the stomach. Prevacid is a proton pump
inhibiter that is used in the treatment of GERD. Elevating the head of the bed is
appropriate once the nasogastric tube has been placed. Regular assessment of bowel
sounds will help determine the presence or absence of peristalsis.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 3

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

10. Clients who have experienced spinal cord injuries (SCI) are faced with many
challenges. After assessing a client who has been admitted for rehabilitation after a fall
that resulted in hemiplegia, the nurse recognizes that the clients care plan related to
psychosocial concerns may require inclusion of nursing diagnoses regarding:
Select all that apply.
1.
2.
3.
4.
5.

Body image.
Independence.
Role performance.
Sensory perception.
Mobility.

Correct Answer:
1. Body image.
2. Independence.
3. Role performance.
Rationale: Body image. Patients who have experienced an SCI experience significant
psychosocial impact. These patients are faced with changes related to loss of body image.
Independence. Patients who have experienced an SCI experience significant
psychosocial impact. These patients are faced with changes related to loss of
independence. Role performance. Patients who have experienced an SCI experience
significant psychosocial impact. These patients are faced with changes related to previous
personal and interpersonal roles. Sensory perception. Sensory perception relates to
physiological changes. Mobility. Mobility relates to physiological changes.
Cognitive Level: Analysis
Nursing Process: Diagnoses
Client Need: Psychosocial Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

11. The nurse is preparing to discuss discharge planning with a patient who is hemiplegic
as a result of a diving accident, and with his wife, who will be his primary caregiver.
Knowledge of the psychosocial needs of the caregiver prompts the nurse to include
information specifically related to:
Select all that apply.
1.
2.
3.
4.
5.

Role changes.
Stress management techniques.
Respite resources.
Bowel and bladder management techniques.
Local rehabilitation services.

Correct Answer:
1. Role changes.
2. Stress management techniques.
3. Respite resources.
Rationale: Role changes. Patients who have experienced a spinal cord injury are not only
faced with the physical challenges associated with this injury, but the patients family
members also will need support and ongoing education to help them deal with the stress
of having a critically ill loved one and the role changes associated with becoming a
primary caregiver. Stress management techniques. In addition to the patients needs, the
patients family members also will need support and ongoing education to help them deal
with the stress of having a critically ill loved one. Stress management is important to the
physical and mental health of the caregiver. Respite resources. Respite options are
important to the physical and mental health of the caregiver. Bowel and bladder
management techniques. Information about care techniques addresses physiological
issues. Exploring the spouses concerns about providing this care would be directed at
psychosocial issues. Local rehabilitation services. Rehabilitation services are by
definition interdisciplinary, addressing physiological and psychosocial needs. Services
are provided to the patient and all family members, not just the primary caregiver.
Cognitive Level: Analysis
Nursing Process: Planning
Client Need: Psychosocial Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

12. Holistic care requires that nurses be competent in providing attention that addresses
the clients needs in areas that are:
Select all that apply.
1.
2.
3.
4.
5.

Physical.
Emotional.
Psychosocial.
Spiritual.
Occupational.

Correct Answer:
1. Physical.
2. Emotional.
3. Psychosocial.
4. Spiritual.
Rationale: Physical. An essential component in providing holistic care to patients is
providing care on all levels, including physical needs. Emotional. An essential
component in providing holistic care to patients is providing care on all levels, including
emotional needs. Psychosocial. An essential component in providing holistic care to
patients is providing care on all levels, including psychosocial needs. Spiritual. An
essential component in providing holistic care to patients is providing care on all levels,
including spiritual needs. Occupational. The nurse must be aware of all aspects of the
patients care, but will not be the primary provider of care related to occupational needs.
Cognitive Level: Application
Nursing Process: Planning
Client Need: Physiological Integrity
LO: 4

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

13. Spinal cord injuries (SCI) often require lengthy, intensive physical rehabilitation that
is provided by a comprehensive plan team that is comprised primarily of:
Select all that apply.
1.
2.
3.
4.
5.

Occupational therapists.
Physical therapists.
Nurses.
Social workers.
Dietitians.

Correct Answer:
1. Occupational therapists.
2. Physical therapists.
3. Nurses.
4. Social workers.
Rationale: Occupational therapists. During the rehabilitation period, the patient will
undergo extensive inpatient occupational therapy. Physical therapists. During the
rehabilitation period, the patient will undergo extensive inpatient physical therapy.
Nurses. Nurses are an integral part of the multidisciplinary team, providing a common
link for all team members as well as providing education and support to the patient and
family through all phases of treatment. Social workers. A social worker and psychologist
will work with patients and their families to assist with psychosocial issues. Dietitians.
Dietary consultation is helpful in the acute phase of care to ensure the patients nutritional
requirements are met. Consultation will be initiated again in the rehab phase if needed.
Cognitive Level: Analysis
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

14. A client with a spinal cord injury (SCI) that has resulted in paraplegia has expressed
doubts about ever being able to give birth to children. The nurse formulates the best
response to the clients concern based on the understanding that:
1. Becoming a biological mother is usually possible regardless of an SCI.
2. Being sexually active will require a supportive partner.
3. Ability to function sexually will be determined by her ability to accept the
physical limitations.
4. Conception is usually by artificial insemination.
Correct Answer: Becoming a biological mother is usually possible regardless of an SCI.
Rationale: Patients will receive advice on maintaining an active lifestyle within the
limitations of their injury. It is important that these patients understand that they can
continue to be sexually active despite their injury. It is even possible for them to have
children in the future if they so desire. While having a supportive sexual partner and
acceptance of physical limitations will be factors in reestablishing sexual activity, they do
not directly address the clients concerns. Most women with spinal cord injuries remain
fertile and can conceive and bear children.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

15. The nurse recognizes that the rehabilitation goal for a client who has experienced a
spinal cord injury (SCI) is to assist the client in:
Select all that apply.
1.
2.
3.
4.
5.

Adapting to the realization of the clients limitations.

Reaching the clients highest potential for independence.
Assimilating back into the clients home environment.
Dealing with the physical pain such injuries cause.
Providing the emotional support required for this adjustment.

Answer:
1. Adapting to the realization of the clients limitations.
2. Reaching the clients highest potential for independence.
3. Assimilating back into the clients home environment.
Rationale: Adapting to the realization of the clients limitations. Rehabilitation for
patients with SCI will consist of a comprehensive program designed to help patients
adapt to the limitations of their injury. Reaching the clients highest potential for
independence. Rehabilitation for patients with SCI will consist of a comprehensive
program designed to help patients reach the highest level of independence possible.
Assimilating back into the clients home environment. Rehabilitation for patients with
SCI will consist of a comprehensive program designed to help patients adapt to
reintegrate into the home environment and community. Dealing with the physical pain
such injuries cause. Physical pain is addressed by the medical and nursing treatment
plans. Providing the emotional support required for this adjustment. Emotional
support is the expertise of psychiatry.
Cognitive Level: Analysis
Nursing Process: Assessment
Category of Client Need: Physiological Integrity
LO: 5

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

16. Subjective assessment of the psychosocial state of a client who has experienced a
spinal cord injury (SCI) can be best achieved when the nurse:
1.
2.
3.
4.

Asks the client to identify members of his support system.

Enters the room and finds the client crying.
Is told by the client that he was once treated for depression.
Overhears the client telling family that this just isnt fair.

Correct Answer: Asks the client to identify members of his support system.
Rationale: Subjective assessment of a clients psychosocial state is best achieved by
assessing the clients own perception of the presence of a support system. Crying is an
objective sign. Expressing a feeling of unfairness relates more to the clients ability to
cope. A history of depression is not necessarily proof of current depression.
Cognitive Level: Application
Nursing Process: Assessment
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

17. A client with a spinal cord injury (SCI) has a nursing diagnosis of Risk for Ineffective
Tissue Perfusion related to the effects of neurogenic shock. The nurse includes which of
the following interventions in the clients plan of care to best address this issue?
Select all that apply.
1.
2.
3.
4.
5.

Utilize abdominal binder and thigh-high compression stockings.

Administer vasoactive agents and atropine as ordered.
Strictly monitor and document intake and output.
Administer anticoagulant medication as ordered.
Assess color, temperature, and size of extremities.

Correct Answer:
1. Utilize abdominal binder and thigh-high compression stockings.
2. Administer vasoactive agents and atropine as ordered.
3. Strictly monitor and document intake and output.
Rationale: Utilize abdominal binder and thigh-high compression stockings.
Utilization of abdominal binder and thigh high compression stockings will help venous
blood return and minimize blood pooling in the abdomen and lower extremities.
Administer vasoactive agents and atropine as ordered. Administer vasoactive agents
and atropine as ordered to ensure adequate blood pressure, heart rate, and cardiac output.
Strictly monitor and document intake and output. Monitor intake and output and
replace intravascular volume to ensure adequate fluid status. Administer anticoagulant
medication as ordered. Administering anticoagulant as ordered is for the prevention of
peripheral DVT. Assess color, temperature, and size of extremities. Assessing color,
temperature, and size of extremities enables early detection and prompt treatment of
DVT.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.

18. Risk for constipation related to impaired gastric motility is added to the nursing care
plan of a client with a spinal cord injury (SCI). The nurse identifies appropriate nursing
interventions as:
Select all that apply.
1.
2.
3.
4.
5.

Administer stool softener as prescribed.

Institute mechanical stimulation to initiate bowel evacuation.
Encourage diet that includes high-fiber foods daily.
Encourage fluid intake of 8 to 10 cups daily.
Check each stool for occult blood.

Correct Answer:
1. Administer stool softener as prescribed.
2. Institute mechanical stimulation to initiate bowel evacuation.
3. Encourage diet that includes high-fiber foods daily.
4. Encourage fluid intake of 8 to 10 cups daily.
Rationale: Administer stool softener as prescribed. To minimize the risk of
constipation in clients with SCI, the nurse should institute a bowel regimen of stool
softener to help establish a regular bowel elimination pattern. Institute mechanical
stimulation to initiate bowel evacuation. To minimize the risk of constipation in clients
with SCI, the nurse should institute a bowel regimen of chemical stimulation such as a
suppository to establish a regular bowel elimination pattern. The patients bowel
elimination pattern should be monitored closely to ensure adequate bowel evacuation.
Encourage diet that includes high-fiber foods daily. Dietary recommendations to aid in
bowel evacuation include ensuring a minimum of 15 grams of dietary fiber per day.
Encourage fluid intake of 8 to 10 cups daily. Dietary recommendations to aid in bowel
evacuation include adequate fluid intake. Check each stool for occult blood. Testing
stool for occult blood is directed toward monitoring for a bleeding gastric ulcer.
Cognitive Level: Analysis
Nursing Process: Implementation
Client Need: Physiological Integrity
LO: 6

Osborn, et al., Test Item File for Medical-Surgical Nursing: Preparation for
Practice Copyright 2010 by Pearson Education, Inc.