Spinal Cord Injury NCLEX Questions And Rationalizations
To become a licensed practical nurse (LPN) or a registered nurse (RN), you must pass the National Council Licensure Examination (NCLEX), which consists of two standardized tests. One of the topic questions revolves around how NCLEX tackles spinal cord injury. If you are still reviewing the NCLEX examination for nurses, you should take note of the spinal cord injury NCLEX questions in this article.
What Is The NCLEX?
The acronym NCLEX refers to the National Council Licensure Exam. A test to see if a potential nurse has the bare minimum of skills and knowledge to provide care to patients in a clinical setting. Exams like the National Council Licensure Examination for Registered Nurses (NCLEX-RN) and the National Council Licensure Examination for Practical Nurses (NCLEX-PN) are developed by the National Council of State Boards of Nursing (NCSBN).
The NCSBN focuses on their objective of safeguarding the public from substandard nursing. All 50 US states, the District of Columbia, and four US territories have nursing boards that are members of the NCSBN.
Who is required to take the NCLEX? The short answer is that anyone who wants to be a nurse will have to take the NCLEX exam and pass it. As we said before, there are two different versions of the NCLEX exam based on education level.
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Those who want to become licensed practical nurses (LPNs) and have a practical nursing diploma must pass the NCLEX-PN. If you have an Associate's or Bachelor's degree and want to become a registered nurse (RN), you have to pass the NCLEX-RN.
Spinal Cord Injury NCLEX Questions
Question 1
A client who has had a spinal cord injury (SCI) in the past says she has a terrible headache and can't see clearly. During the assessment, the nurse notices that the person has high blood pressure, a slow heart rate, and a red face. Which one of the following should the nurse do first?
A. Apply compression stockings
B. Lower the head of the bed
C. Empty the client’s bladder
D. Increase the IV flow rate
Correct Answer: C. Empty the client's bladder
Rationale: The client is showing signs of autonomic dysreflexia, which is a medical emergency that needs help right away. Autonomic dysreflexia can be caused by a swollen bladder or rectum, an infection in the urinary tract, or some other kind of sensory stimulation below the spinal cord lesion.
The sensory stimulation causes a large sympathetic discharge, which causes the blood vessels to narrow and the blood pressure to rise. In response, baroreceptors in the carotid sinus cause a parasympathetic outflow above the level of the cord lesion, which causes the face to flush and the heart rate to slow down.
Question 2
"I can't feel my legs anymore," yells a hospitalized patient with a C7 cord injury. Which of the nurse's actions is the most appropriate?
A. Remind the patient of her injury and offer her comfort.
B. Contact your healthcare provider and request a radiologic evaluation.
C. As the patient's condition worsens, prepare her for surgery.
D. Inform the patient that this could be a common, temporary issue.
Correct Answer: D. Inform the patient that this could be a common, temporary issue.
Rationale: Spinal shock is a condition that happens to almost half of the people who have an acute spinal injury. It is marked by a temporary loss of reflex function below the level of injury. Symptoms include flaccid paralysis of skeletal muscles, loss of sensation below the injury, and possibly problems with the bowels and bladders and inability to sweat below the injury level. In this case, the nurse needs to tell the patient what's going on.
Question 3
The nurse is looking after a patient who has high intracranial pressure (IICP). The nurse recognizes that some nursing actions are incompatible with IICP. Which nursing procedures should be avoided?
A. Every two hours, reposition the patient.
B. Raise the patient's head 30 degrees above the ground.
C. As per standard procedure, suction the airway every two hours.
D. As directed, provide continuous oxygen.
Correct Answer: D. As directed, provide continuous oxygen.
Rationale: Suctioning raises intracranial pressure even more. Because of this, suctioning should be done to keep an airway open but not as a matter of course. IICP can be prevented or even lessened by making sure the patient is comfortable by moving them around often and keeping their heads up at 30 degrees. Getting enough oxygen to the patient may also help control ICP.
Question 4
A T1 spinal cord injury patient complains of a severe headache and a "anxious feeling." Which of the following is the most appropriate initial reaction by the nurse?
A. Attempt to calm the patient and create a soothing environment.
B. Examine for a full bladder.
C. Inform your healthcare provider.
D. Get the patient ready for diagnostic radiography.
Correct Answer: "B. Examine for a full bladder."
Rationale: Patients with injuries at level T6 or higher can get autonomic dysreflexia, which is a life-threatening situation that must be treated right away or the patient will die. The most common cause is a bladder or bowel that is too full. Symptoms include high blood pressure, headache, sweating, slow heart rate, changes in vision, anxiety, and feeling sick. Even though a calm, soothing environment is nice, the patient doesn't need that in this case. The nurse should know that this is a serious situation and act accordingly. After the evaluation is done, the results will need to be shared with the healthcare provider.
Question 5
Which patient is most likely to sustain a spinal cord injury?
A. An 18-year-old male who has previously been arrested for driving while intoxicated (DWI)
B. A female, 20 years old, with a history of substance abuse
C. A 50-year-old woman suffering from osteoporosis
D. 35-year-old male coach of a soccer team
Correct Answer: A. An 18-year-old male who has previously been arrested for driving while intoxicated (DWI)
Rationale: The three major risk factors for spinal cord injuries (SCI) are age (young adults), gender (males have a higher incidence), and alcohol or drug abuse. Females are less likely to engage in risky behavior than young men.
Testing Time For NCLEX
The NCLEX-RN test can take up to six (6) hours, and there is no set amount of time for each question. All of the tutorials and all of the breaks are part of the exam time. The first break comes after two (2) hours of testing, and the second comes after 3.5 hours. All breaks are optional, and most people probably won't need the full amount of time to finish the test.
People Also Ask
What Causes An Initial Incomplete Spinal Cord Injury To Result In Complete Cord Damage?
Vehicle accidents (39.3%), falls (31.8%), violence (13.5%), and primarily gunshot wounds are the leading causes of both complete and incomplete spinal cord injuries.
What Is C7 Spinal Cord Injury?
Individuals suffering from a C7 spinal cord injury may experience limited or absent sensation (feeling) or movement below the shoulders and/or neck. This can make moving or feeling anything in the lower body, trunk, and sometimes even the hands and fingers difficult.
What Is The Most Common Complication Of Spinal Cord Injury?
Pressure ulcers are a common complication of spinal cord injury. Individuals at risk of developing pressure ulcers must be identified for effective prevention[49]. The most common long-term complication in SCI is a pressure ulcer.
Final Thoughts
Having a genuine interest in helping others and making a positive impact on their lives has always been a passion of yours, right? Do those closest to you agree that you have a keen mind and a kind heart? If that's the case, they probably weren't shocked to hear that you wanted to become a nurse.
However, to become a registered nurse, you must pass the NCLEX. This article's questions are meant to give you a taste of the sorts of things you might be asked on the exam.
As far as NCLEX is concerned, the NCSBN establishes the criteria and selection process for registered nurses who write items. Many of them are advanced degree-holding nursing educators, so if you've completed an accredited nursing program, you've already taken several tests written by nurses with backgrounds similar to those who write for the NCLEX.
According to the NCSBN, three rules govern pass-or-fail decisions: the 95% Confidence Interval Rule, the Maximum-Length Exam Rule, and the Run-Out-Of-Time Rule.
About The Authors
Dr. Bill Butcher - With more than two decades of experience, Dr. Bill Butcher aims to provide a repository for educational materials, sources of information, details of forthcoming events, and original articles related to the medical field and about health subjects that matter to you. His goal is to help make your life better, to help you find your way when faced with healthcare decisions, and to help you feel better about your health and that of your family.Bill received his medical degree at Boston University School of Medicine and spent his entire career helping people find the health and medical information, support, and services they need. His mission is to help millions of people feel fantastic by restoring them to optimal health.