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A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
- A. Diffuse axonal injury
- B. Grade 1 concussion with frontal lobe involvement
- C. Contusion
- D. Grade 3 concussion with temporal lobe involvement
Correct Answer: D
Rationale: Grade 3 concussion with temporal lobe involvement causes prolonged unconsciousness and amnesia, with normal MRI. Grade 1 has no loss of consciousness, and DAI or contusion typically show structural damage.
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The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
- A. Absence of pain response
- B. Apnea
- C. Coma
- D. Absence of brain stem reflexes
- E. Absence of deep tendon reflexes
Correct Answer: B,C,D
Rationale: Brain death is defined by coma, apnea, and absent brain stem reflexes. Pain response and deep tendon reflexes are not cardinal signs.
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
- A. Administer an IV bolus of normal saline prior to repositioning.
- B. Maintain bed rest until normal BP regulation returns.
- C. Monitor the patients BP before and during position changes.
- D. Allow the patient to initiate repositioning.
Correct Answer: C
Rationale: Monitoring BP during position changes helps manage orthostatic hypotension. Boluses are impractical, bed rest carries risks, and patient-initiated changes may not prevent hypotension.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
- A. Sports-related injuries
- B. Acts of violence
- C. Injuries due to a fall
- D. Motor vehicle accidents
Correct Answer: D
Rationale: Motor vehicle accidents account for 46% of SCIs, making them the most common cause, followed by falls, violence, and sports injuries.
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
- A. Change the patients position frequently.
- B. Provide a high-protein diet.
- C. Provide light massage at least daily.
- D. Teach the patient deep breathing and coughing exercises.
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
- A. Hyperthermia
- B. Tachycardia
- C. Hypertension
- D. Bradypnea
Correct Answer: A
Rationale: Hyperthermia indicates brain stem damage due to increased metabolic demands. Bradycardia, rising systolic BP, and rapid respirations are earlier ICP signs, while bradypnea occurs later.