Note credit will be given only if all correct choices

Note: Credit will be given only if all correct choices and no incorrect choices are selected.
Standard Text: Select all that apply.
1. Monitoring skin temperature in lower extremities
2. Assessing for abdominal distention
3. Bladder scan postvoiding
4. Assessing pulse oximetry levels with vital signs
5. Strict output monitoring
Correct Answer: 2,3,5
Rationale 1 : Monitoring lower-extremity skin temperature is appropriate for detecting deep vein thrombosis.
Rationale 2 : Causes of autonomic hyperreflexia are impacted stool or constipation, so assessing for abdominal
distention is appropriate.
Rationale 3 : The nurse caring for spinal cord injury (SCI) patients should be attuned to the prevention of a
distended bladder to prevent the chain of events that leads to autonomic hyperreflexia. Scanning the bladder
postvoiding can detect residual urine retention.
Rationale 4 : Pulse oximetry is effective in monitoring for a decline in oxygen saturation and may be the initial
indicator of a pulmonary embolus.
Rationale 5 : Tracking urinary output carefully can help detect residual urine retention.
Global Rationale:
Cognitive Level: Analyzing
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Assessment
Learning Outcome: 24-5
Question 24

Type: MCSA
A patient is admitted after a fall that has resulted in spinal shock. When asked by the family how long the
paralysis is likely to last, the nurse's response is based on which understanding?
1. Spinal shock usually results in temporary paralysis.
2. There will likely be some minor improvement in the degree of paralysis.
3. Spinal shock is irreversible and the paralysis is likely to be permanent.
4. The severity of the injuries cannot be determined until the spinal shock resolves.
Correct Answer: 4
Rationale 1 : At this point it is not possible to determine whether the paralysis is temporary or permanent or will
lessen.
Rationale 2 : There is no assurance that the paralysis will lessen.
Rationale 3 : 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 period, it is impossible to determine the extent of the SCI.
Rationale 4 : 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. It is not possible to determine the severity of the injury until spinal shock has
abated.
Global Rationale:
Cognitive Level: Applying
Client Need: Physiological Integrity
Client Need Sub: Physiological Adaptation
Nursing/Integrated Concepts: Nursing Process: Planning
Learning Outcome: 24-3
Question 25
Type: MCSA
A patient with a recent spinal cord injury is at risk for complications to the gastrointestinal system. Which nursing
intervention is primarily directed at minimizing this risk?