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A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?
- A. When the patients condition begins to deteriorate
- B. As soon as the initial assessment is made
- C. At the beginning of each shift
- D. When there is a clinically significant change in the patients condition
Correct Answer: B
Rationale: A neurologic flow chart starts with the initial assessment to track changes consistently. It is not limited to deterioration or shift changes.
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A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
- A. Epidural hemorrhage
- B. Hypertensive emergency
- C. Spinal shock
- D. Hypovolemia
Correct Answer: C
Rationale: Spinal shock causes absent reflexes, flaccidity, and hypotension below the injury level. Other conditions do not produce this specific reflex depression.
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
- A. Reflex activity
- B. Level of consciousness
- C. Cognitive ability
- D. Sensory involvement
Correct Answer: B
Rationale: The GCS assesses level of consciousness through eye, verbal, and motor responses. It does not evaluate reflexes, cognition, or sensory function.
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.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
- A. Complete the pin site care to decrease risk of infection.
- B. Notify the neurosurgeon of the occurrence.
- C. Stabilize the head in a lateral position.
- D. Reattach the pin to prevent further head trauma.
Correct Answer: B
Rationale: A detached halo pin requires immediate neurosurgeon notification to prevent injury. Stabilizing the head in neutral, not lateral, position is secondary, and reattaching or cleaning is unsafe.
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.