Nokea
A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?
- A. The patient will be unable to use a wheelchair.
- B. The patient will be unable to swallow food.
- C. The patient will be continent of urine, but incontinent of bowel.
- D. The patient will require full assistance for all aspects of elimination.
Correct Answer: D
Rationale: C4 SCI causes dependency for elimination due to loss of voluntary control. Patients can use electric wheelchairs and swallow food, and continence is not preserved.
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The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
- A. Ensure that the player is not moved.
- B. Obtain the players vital signs, if possible.
- C. Perform a rapid assessment of the players range of motion.
- D. Assess the players reflexes.
Correct Answer: A
Rationale: Immobilizing the patient prevents worsening of a potential SCI. Assessing vitals, ROM, or reflexes risks further injury.
A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?
- A. Repositioning the patient every 2 hours
- B. Initiating range-of-motion exercises (ROM) as soon as the patient initiates
- C. Initiating (ROM) exercises as soon as possible after the injury
- D. Performing ROM exercises once a day
Correct Answer: C
Rationale: Early passive ROM exercises prevent contractures. Waiting for patient initiation or daily exercises is insufficient, and repositioning alone does not address contractures.
The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
- A. Promoting adequate circulation
- B. Treating the childs increased ICP
- C. Assessing secondary brain injury
- D. Preserving brain homeostasis
Correct Answer: D
Rationale: Preserving brain homeostasis prevents secondary brain injury and guides initial therapy. Specific ICP treatment or circulation focus is secondary.
The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
- A. Limit the amount of assistance provided with ADLs.
- B. Collaborate with the physical therapist and immobilize the patients extremities temporarily.
- C. Increase the frequency of ROM exercises.
- D. Educate the patient about the importance of frequent position changes.
Correct Answer: C
Rationale: Increasing ROM exercise frequency prevents disuse syndrome by maintaining joint mobility. Limiting ADLs or immobilizing extremities worsens disuse, and education alone is insufficient.
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?
- A. Insertion of an intracranial monitoring device
- B. Treatment with antihypertensives
- C. Emergency craniotomy
- D. Administration of anticoagulant therapy
Correct Answer: C
Rationale: Epidural hematoma is a surgical emergency requiring craniotomy to remove the clot and control bleeding. Anticoagulants are contraindicated, and monitoring or antihypertensives are not priorities.