NURS 111 Spinal Cord Injury Exam. Columbia University. Complete Solution.At the Scene
All of Jonathan's friends are standing around him, unsure about
... [Show More] what to do. They are afraid that he is badly
hurt. Jonathan thinks it is just a temporary sting and states that he will be all right in a few minutes. One of the
men calls 911 on a cell phone.
1.
What should Jonathan's friends do while waiting for emergency personnel to arrive?
A) Help Jonathan move his legs and assist him to sit up.
INCORRECT
No one should help Jonathan move his legs or assist him.
B) Place a blanket over Jonathan and make sure no one moves him.
CORRECT
Any movement or improper handling could cause further damage and loss of neurological function.
C) Attempt to stabilize his neck with any type of soft material.
INCORRECT
Any attempt to manipulate the neck could cause further damage and loss of neurological function.
D) Carefully put Jonathan in the back of a truck with one man holding his neck.
INCORRECT
Any action that manipulates the neck could cause further damage and loss of neurological function.
Points Earned: 0.0/1.0
Correct Answer(s): B
An ambulance arrives within a few minutes. Two paramedics and an Emergency Department (ED) nurse on a
"ridealong" quickly take control of the situation. The nurse assists the paramedics as they prepare Jonathan
for transport to the trauma center.
2.
If respiratory compromise occurs, what action should the nurse take to keep the airway open without
compromising Jonathan's spine further?
A) Logroll to side while maintaining neutral alignment.
INCORRECT
This action would be used to move an injured person from a prone position to supine if respiratory compromise
occurs. It is not the best way to open the airway of a person who is already in the supine position.
B) Perform the jawthrust technique.
CORRECT
The jawthrust is the safest first approach to opening the airway of a casualty who has a suspected neck injury
because in most cases it can be accomplished without extending the neck.
C) Flex the neck with a wedge pillow.
INCORRECT
This action could cause further damage to the spinal cord as it stretches the back of the neck.
D) Use the chinlift/head tilt technique.
INCORRECT
This technique causes extension of the neck and could cause further damage.
Points Earned: 1.0/1.0
Correct Answer(s): B
Keeping the head, neck, and spinal column in a neutral position, the paramedics and the nurse apply a cervical
collar and place Jonathan on a scoop stretcher. A large bore IV is started and oxygen is applied at 8
liters/minute using nasal prongs. Jonathan is transported to the trauma center via ambulance.
Clinical Manifestations
When Jonathan is admitted to the emergency department, the trauma nurse performs a neurological
assessment.
3.
Which intervention has highest priority when assessing Jonathan?
A) Palpate the lower abdomen for any signs of urinary retention.
INCORRECT
Although urinary retention is assessed to help diagnose spinal shock, it does not have the highest priority.
B) Assess sensation by gently pinching the skin distal to proximal.
INCORRECT
Although sensation is evaluated in this manner, this assessment does not have the highest priority.
C) Assess Jonathan's breathing pattern and his ability to cough.
CORRECT
Since a cervical spinal cord injury is suspected, the nurse must be aware that edema may ascend the spinal
cord, which can compromise breathing and coughing. Breathing is always the priority, especially when there is
the possibility that oxygenation might be impaired.
D) Monitor the client's vital signs, especially a tympanic temperature.
INCORRECT
An autonomic disruption may cause an alteration in temperature, but this assessment does not have the
highest priority.
Points Earned: 1.0/1.0
Correct Answer(s): C
The nurse completes the admission assessment and documents the findings in the nurse’s notes. [Show Less]