Nokea
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
- A. Risk for impaired skin integrity related to immobility.
- B. Impaired physical mobility related to loss of motor function.
- C. Ineffective breathing patterns related to weakness of the intercostal muscles.
- D. Unable to void spontaneously due to neurogenic bladder.
Correct Answer: C
Rationale: Ineffective breathing is the priority due to C4 SCI affecting diaphragmatic and intercostal function, often requiring ventilatory support. Other diagnoses are secondary in immediate care.
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The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
- A. Baclofen (Lioresal)
- B. Dexamethasone (Decadron)
- C. Mannitol (Osmitrol)
- D. Phenobarbital (Luminal)
Correct Answer: A
Rationale: Baclofen is an antispasmodic used for SCI-related spasticity. Dexamethasone reduces inflammation, mannitol treats cerebral edema, and phenobarbital is for seizures.
A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
- A. MRI
- B. PET scan
- C. X-ray
- D. Ultrasound
Correct Answer: A
Rationale: MRI is the primary tool for evaluating brain structure in diffuse axonal injury. PET scans assess function, while X-rays and ultrasound are inadequate for brain imaging.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
- A. The patient received a blood transfusion.
- B. The patients analgesia regimen was recent changed.
- C. The patient was not repositioned during the night shift.
- D. The patients urinary catheter became occluded.
Correct Answer: D
Rationale: A distended bladder from catheter occlusion is the most common trigger for autonomic dysreflexia. Other options are less likely causes.
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
- A. Absence of reflexes along with flaccid extremities
- B. Positive Babinskis reflex along with spastic extremities
- C. Hyperreflexia along with spastic extremities
- D. Spasticity of all four extremities
Correct Answer: A
Rationale: Spinal shock results in absent reflexes and flaccid extremities. Spasticity and hyperreflexia occur after spinal shock resolves.
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.