Question

A nurse is caring for a client who has sustained a spinal cord injury and is currently in spinal shock. Which nursing intervention takes priority to prevent further spinal cord damage?

Answer 1

Correct Answers:

Maintain the client's mean arterial pressure at or above 85 mm Hg.

Rationale :

🔹 Maintaining mean arterial pressure (MAP) at or above 85 mm Hg is the priority because adequate spinal cord perfusion helps limit secondary ischemic injury after acute spinal cord trauma.

🔹 When blood pressure is too low, the injured cord receives less oxygen and nutrients, which can worsen neurologic damage.

🔹 Current spinal cord injury guidance commonly supports maintaining MAP 85 to 90 mm Hg during the early postinjury period to improve cord blood flow.

🔹 This intervention directly protects the injured spinal cord, which makes it a higher priority than comfort-focused or secondary supportive measures.

🔹 For this reason, maintaining MAP at or above 85 mm Hg is the best answer.

Encourage early mobilization to prevent deep vein thrombosis

🔹 Preventing deep vein thrombosis is important after spinal cord injury, but it is not the first priority over preserving spinal cord perfusion.

🔹 The nurse must first prevent additional cord damage before focusing on later complications of immobility.

Use warming blankets to treat hypothermia associated with spinal shock

🔹 Warming measures may be useful if the client is hypothermic, but they do not directly prevent further spinal cord ischemia.

🔹 Supporting perfusion pressure is more urgent than passive temperature management in this setting.

Administer intravenous corticosteroids to reduce inflammation immediately

🔹 High-dose corticosteroids are not the priority intervention in current spinal cord injury management.

🔹 Perfusion support with adequate MAP is the more important immediate nursing priority for protecting the cord.

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Answer 2

Correct Answers:

History of intracranial hemorrhage.

Rationale :

🔷 A history of intracranial hemorrhage is an exclusion because thrombolytic therapy can increase the risk of catastrophic bleeding inside the skull.

🔷 Tissue plasminogen activator is used to dissolve clots in ischemic stroke, but it can be dangerous in patients with a prior brain bleed.

🔷 Stroke thrombolysis guidance lists history of intracranial hemorrhage among major exclusion criteria.

🔷 Because this history greatly raises bleeding risk, the patient would not be considered an appropriate tPA candidate.

Onset of symptoms 2 hours ago

🔷 Symptom onset 2 hours ago falls within the usual treatment window for thrombolytic therapy.

🔷 This finding supports eligibility rather than excluding the patient.

Blood pressure of 178/96 mm Hg

🔷 A blood pressure of 178/96 mm Hg is below the common exclusion threshold of 185/110 mm Hg used for IV thrombolysis.

🔷 This blood pressure would not automatically exclude the patient from receiving tPA.

Blood glucose of 110 mg/dL

🔷 A blood glucose of 110 mg/dL is within normal range and does not exclude thrombolytic treatment.

🔷 Glucose problems become concerning when values are markedly abnormal, not when they are normal.

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Answer 3

Correct Answers:

Renal calculi from Increased calcium excretion
Respiratory failure due to diaphragm paralysis
Pressure ulcers from prolonged immobility
Deep vein thrombosis and pulmonary embolism

Rationale :

Renal calculi from increased calcium excretion

✅ Clients with tetraplegia are at increased risk for renal calculi because prolonged immobility promotes bone demineralization and increased calcium loss.

✅ Immobility-related calcium mobilization can contribute to stone formation in the urinary tract.

✅ This complication is clinically important in spinal cord injury because urinary problems are common and can worsen morbidity.

✅ Tetraplegic clients often have multiple secondary complications related to immobility and altered elimination.

Respiratory failure due to diaphragm paralysis

✅ Tetraplegia, especially from high cervical injury, can impair the diaphragm and intercostal muscles, causing serious respiratory compromise.

✅ Respiratory complications are among the most dangerous early and long-term consequences of spinal cord injury.

✅ A client with inadequate respiratory muscle function can rapidly develop hypoventilation and respiratory failure.

✅ Because breathing is essential for survival, this is one of the highest-priority complications in tetraplegia.

Pressure ulcers from prolonged immobility

✅ Tetraplegic clients are at high risk for pressure ulcers because they cannot effectively reposition themselves and often have reduced sensation.

✅ Prolonged pressure over bony prominences decreases tissue perfusion and causes skin breakdown.

✅ Pressure injuries are among the most common secondary complications after spinal cord injury.

✅ Prevention requires vigilant skin care, turning, and pressure relief.

Deep vein thrombosis and pulmonary embolism

✅ Clients with tetraplegia are at increased risk for deep vein thrombosis and pulmonary embolism because immobility promotes venous stasis.

✅ Spinal cord injury is a major risk factor for thromboembolic events, especially early after injury.

✅ Pulmonary embolism can become life-threatening if a clot travels to the lungs.

✅ Nursing care must include vigilance for DVT signs, prophylaxis, and early preventive strategies when appropriate.

Hyperglycemia due to increased metabolic demand

✅ Hyperglycemia due to increased metabolic demand is not a classic priority complication specifically associated with tetraplegia.

✅ The more expected priority risks are respiratory compromise, skin breakdown, renal complications, and thromboembolism.

Hypertension caused by increased autonomic nervous system activity

✅ Persistent hypertension is not the general expected priority complication in tetraplegia as stated here.

✅ Autonomic dysfunction can occur in spinal cord injury, but the major priority risks listed more directly match recognized complications.

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Answer 4

Correct Answers:

Decreased concentration
Impulsivity
Loss of memory

Rationale :

Decreased concentration

💠 Decreased concentration is a cognitive change because traumatic brain injury often affects attention, focus, and information processing.

💠 Clients may struggle to stay on task, follow conversations, or process new information efficiently.

💠 These attention problems are common after brain injury and interfere with learning and safety.

💠 Difficulty concentrating reflects impaired cognitive functioning rather than a purely emotional reaction.

Impulsivity

💠 Impulsivity is a cognitive-behavioral change that often occurs when brain injury affects executive functioning and self-control.

💠 Clients may act quickly without thinking through consequences or safety risks.

💠 This reflects impaired judgment and reduced inhibitory control, both of which are cognitive deficits.

💠 Impulsivity can interfere with rehabilitation, relationships, and adherence to care.

Loss of memory

💠 Loss of memory is a classic cognitive change after traumatic brain injury.

💠 Clients may have difficulty recalling recent events, retaining new information, or recovering details from before the injury.

💠 Memory impairment can affect daily functioning, safety, and participation in rehabilitation.

💠 It directly reflects disruption in brain processes responsible for storing and retrieving information.

Frustration

💠 Frustration is better classified as an emotional response than a cognitive deficit.

💠 It may occur because of the injury’s effects, but it is not itself a cognitive change.

Anxiety

💠 Anxiety is an emotional or psychological response rather than a cognitive impairment.

💠 The question asks specifically for cognitive changes, so this option should not be selected.

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Answer 5

Correct Answers:

Hemorrhagic stroke

Rationale :

🔶 Hemorrhagic stroke is the best answer because it commonly presents with sudden severe headache, vomiting, seizures, altered consciousness, and marked hypertension.

🔶 Bleeding in or around the brain irritates neural tissue and can abruptly raise intracranial pressure.

🔶 This explains the combination of headache, vomiting, seizure activity, and becoming unresponsive.

🔶 The blood pressure of 198/110 mm Hg strongly supports a bleeding event rather than a transient or minor neurologic episode.

Thrombotic stroke

🔶 Thrombotic stroke usually does not classically present with a sudden thunderclap headache and seizure as the leading features.

🔶 The dramatic headache and vomiting pattern is much more suggestive of hemorrhage.

Transient ischemic attack (TIA)

🔶 A TIA causes temporary neurologic deficits without persistent major findings from intracranial bleeding.

🔶 Seizure, severe headache, vomiting, and unresponsiveness make TIA much less likely.

Embolic stroke

🔶 Embolic stroke can cause sudden deficits, but the combination of severe headache, vomiting, seizure, and severe hypertension is more typical of hemorrhagic stroke.

🔶 The symptom cluster fits bleeding into the brain better than embolic occlusion.

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Answer 6

Correct Answers:

11

Rationale :

✍️165 lb ÷ 2.2 = 75 kg.

✍️4 mcg × 75 kg = 300 mcg/min.

✍️300 mcg/min × 60 = 18,000 mcg/hr = 18 mg/hr.

✍️400 mg ÷ 250 mL = 1.6 mg/mL,

✍️18 mg/hr ÷ 1.6 mg/mL

📍11.25 mL/hr.

📍Rounded to the nearest whole number, the IV pump should be set at 11 mL/hr.

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Answer 7

Correct Answers:

Encourage the client to consume a diet high in fiber, maintain adequate hydration, and establish a consistent bowel elimination schedule.

Rationale :

🍃 A regular bowel program after spinal cord injury is built around scheduled elimination, adequate fluids, and appropriate dietary support to reduce constipation and impaction.

🍃 Consistency helps train the bowel and promotes more predictable emptying.

🍃 Adequate hydration softens stool and makes elimination easier, while dietary fiber can support bowel regularity when tolerated.

🍃 This combination addresses the underlying bowel dysfunction more effectively than relying on one single measure alone.

🍃 For this reason, encouraging fiber, hydration, and a consistent bowel schedule is the best intervention.

Restrict fluid intake to minimize bowel incontinence and decrease frequency of bowel movements

🍃 Restricting fluids can worsen constipation and increase the risk of hard stool and impaction.

🍃 Adequate hydration is an important part of bowel management after spinal cord injury.

Advise the client to avoid physical activity to prevent exacerbation of spinal cord injury symptoms

🍃 Avoiding all activity does not support bowel health and may worsen immobility-related complications.

🍃 Within safe limits, mobility and routine help support regular bowel function.

Rely solely on stimulant laxatives daily to induce bowel movements without adjusting diet or fluid intake

🍃 Using stimulant laxatives alone ignores the broader bowel program needed for long-term management.

🍃 Effective bowel care includes scheduling, fluids, diet, and individualized interventions, not medication alone.

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Answer 8

Correct Answers:

Sudden onset of dyspnea and hypoxia with chest pain

Rationale :

▶️ Pulmonary embolism commonly presents with sudden dyspnea, hypoxia, and chest pain, making this an urgent finding that requires immediate action.

▶️ PE occurs when a clot obstructs blood flow in the lungs, impairing oxygenation and straining the cardiopulmonary system.

▶️ In a client with recent spinal cord injury, immobility increases the risk for venous thromboembolism, so this symptom cluster is especially concerning.

▶️ Delay in recognition can rapidly lead to deterioration or death.

▶️ For this reason, sudden onset of dyspnea and hypoxia with chest pain is the priority indicator.

Presence of paraplegia and absent deep tendon reflexes

▶️ These findings reflect neurologic deficits from spinal cord injury, not an acute pulmonary embolism.

▶️ They do not explain sudden cardiopulmonary compromise.

Gradual onset of muscle weakness below the level of injury

▶️ Progressive weakness below the injury level suggests neurologic changes, not the classic abrupt presentation of PE.

▶️ Pulmonary embolism is more associated with sudden respiratory symptoms.

Development of neurogenic shock with hypotension and bradycardia

▶️ Neurogenic shock is a different complication related to spinal cord injury rather than embolic obstruction in the lungs.

▶️ The question asks for the urgent indicator of PE, which is best reflected by sudden dyspnea, hypoxia, and chest pain.

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Answer 9

Correct Answers:

Provide consistent emotional support and encourage expression of feelings.
Encourage involvement in structured group therapy or rehabilitation activities.
Encourage patient to express feelings and frustrations.

Rationale :

Provide consistent emotional support and encourage expression of feelings

💎 Emotional deficits such as apathy, emotional lability, and impaired self-awareness can interfere with recovery after stroke, so ongoing support is important.

💎 Encouraging the client to talk about feelings helps reduce isolation and supports adaptation to sudden life changes.

💎 Consistent support also helps the nurse identify worsening mood symptoms or barriers to rehabilitation.

💎 Emotional care is part of comprehensive stroke recovery, not something separate from physical rehab.

💎 For this reason, provide consistent emotional support and encourage expression of feelings is correct.

Encourage involvement in structured group therapy or rehabilitation activities

💎 Structured therapy and rehabilitation activities can improve coping, engagement, and participation after stroke.

💎 These settings provide routine, social support, and opportunities to practice communication and adaptive strategies.

💎 Clients with apathy or emotional lability often benefit from guided therapeutic involvement rather than isolation.

💎 Rehabilitation also supports recovery by addressing both emotional and functional deficits together.

💎 Therefore, encouraging involvement in structured group therapy or rehabilitation activities is correct.

Encourage patient to express feelings and frustrations

💎 Encouraging the patient to express feelings and frustrations helps validate the emotional impact of stroke.

💎 Verbal expression can reduce distress and helps the nurse assess emotional adjustment more accurately.

💎 Stroke survivors may experience fear, grief, embarrassment, and loss of control, so therapeutic communication is essential.

💎 Supporting open expression promotes trust and improves engagement in recovery.

💎 For that reason, encourage patient to express feelings and frustrations is also correct.

Delay education about stroke and recovery until emotional status normalizes

💎 Education should be adjusted to the client’s emotional state, but it should not be completely delayed until emotions are fully normal.

💎 Ongoing, supportive, paced teaching is more appropriate than withholding education altogether.

Discourage the patient from discussing fears or frustrations to avoid upsetting them

💎 Discouraging discussion blocks therapeutic communication and prevents emotional support.

💎 Clients benefit from being allowed to express fears in a safe and supportive way.

Ignore emotional outbursts as they are expected and will resolve spontaneously

💎 Emotional outbursts should not be ignored because they may affect safety, coping, and participation in care.

💎 These behaviors require assessment and supportive intervention, not passive dismissal.

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Answer 10

Correct Answers:

Blood urea nitrogen (BUN)

Rationale :

✔️ Mannitol is an osmotic diuretic, so the nurse should monitor renal function closely during therapy.

✔️ BUN helps assess kidney function and can indicate whether the client is tolerating the medication appropriately.

✔️ Mannitol can affect fluid balance and place stress on the kidneys, especially if renal perfusion becomes impaired.

✔️ Monitoring BUN helps identify developing renal complications early.

Glucose

✔️ Glucose is not the primary lab used to monitor the main adverse effects of mannitol.

✔️ Renal function and fluid status are more clinically relevant during osmotic diuretic therapy.

WBC count

✔️ WBC count evaluates infection or inflammation, not the main risk profile of mannitol administration.

✔️ It does not specifically reflect the renal effects the nurse is most concerned about.

Uric acid level

✔️ Uric acid is not the routine priority laboratory value for monitoring mannitol therapy.

✔️ Kidney function indicators such as BUN are more directly useful in this setting.

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QLexNursing

1 :
A nurse is caring for a client who has sustained a spinal cord injury and is currently in spinal shock. Which nursing intervention takes priority to prevent further spinal cord damage?

2 :
A nurse in the emergency department is assessing a patient with suspected acute ischemic stroke for eligibility to receive tissue plasminogen activator (tPA). Which finding would exclude the patient from receiving tPA?

3 :
A client with tetraplegia is at increased risk for several complications due to the level of spinal cord injury. Which of the following risks should the nurse prioritize in the care plan? (Select all that apply).

4 :
There are physical, cognitive, and emotional changes the client experiences after a traumatic brain injury. Which of the following changes does the nurse discuss with the client as cognitive changes? Select all that apply.

7 :
A nurse is developing a care plan for a client with a recent spinal cord injury who is at risk for bowel complications. Which intervention should the nurse prioritize to effectively prevent bowel impaction and maintain regular bowel function?

8 :
A patient with a recent spinal cord injury is suspected of having a pulmonary embolism (PE). Which clinical manifestation should the nurse prioritize as an urgent indicator of PE requiring immediate intervention?

9 :
A patient who experienced a stroke is showing emotional deficits including apathy, emotional lability, and impaired self-awareness. Which nursing actions are appropriate to address these emotional deficits? (Select all that apply).

10 :
A client is receiving IV mannitol. The nurse should monitor which of the following laboratory results for this client?

QLexNursing

1 : A nurse is caring for a client who has sustained a spinal cord injury and is currently in spinal shock. Which nursing intervention takes priority to prevent further spinal cord damage?

2 : A nurse in the emergency department is assessing a patient with suspected acute ischemic stroke for eligibility to receive tissue plasminogen activator (tPA). Which finding would exclude the patient from receiving tPA?

3 : A client with tetraplegia is at increased risk for several complications due to the level of spinal cord injury. Which of the following risks should the nurse prioritize in the care plan? (Select all that apply).

4 : There are physical, cognitive, and emotional changes the client experiences after a traumatic brain injury. Which of the following changes does the nurse discuss with the client as cognitive changes? Select all that apply.

7 : A nurse is developing a care plan for a client with a recent spinal cord injury who is at risk for bowel complications. Which intervention should the nurse prioritize to effectively prevent bowel impaction and maintain regular bowel function?

8 : A patient with a recent spinal cord injury is suspected of having a pulmonary embolism (PE). Which clinical manifestation should the nurse prioritize as an urgent indicator of PE requiring immediate intervention?

9 : A patient who experienced a stroke is showing emotional deficits including apathy, emotional lability, and impaired self-awareness. Which nursing actions are appropriate to address these emotional deficits? (Select all that apply).

10 : A client is receiving IV mannitol. The nurse should monitor which of the following laboratory results for this client?

1 :
A nurse is caring for a client who has sustained a spinal cord injury and is currently in spinal shock. Which nursing intervention takes priority to prevent further spinal cord damage?

2 :
A nurse in the emergency department is assessing a patient with suspected acute ischemic stroke for eligibility to receive tissue plasminogen activator (tPA). Which finding would exclude the patient from receiving tPA?

3 :
A client with tetraplegia is at increased risk for several complications due to the level of spinal cord injury. Which of the following risks should the nurse prioritize in the care plan? (Select all that apply).

4 :
There are physical, cognitive, and emotional changes the client experiences after a traumatic brain injury. Which of the following changes does the nurse discuss with the client as cognitive changes? Select all that apply.

7 :
A nurse is developing a care plan for a client with a recent spinal cord injury who is at risk for bowel complications. Which intervention should the nurse prioritize to effectively prevent bowel impaction and maintain regular bowel function?

8 :
A patient with a recent spinal cord injury is suspected of having a pulmonary embolism (PE). Which clinical manifestation should the nurse prioritize as an urgent indicator of PE requiring immediate intervention?

9 :
A patient who experienced a stroke is showing emotional deficits including apathy, emotional lability, and impaired self-awareness. Which nursing actions are appropriate to address these emotional deficits? (Select all that apply).

10 :
A client is receiving IV mannitol. The nurse should monitor which of the following laboratory results for this client?