Nokea
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.
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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.
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 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.
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
- A. At the patients request
- B. Each morning and evening
- C. Every 2 hours
- D. One hour prior to mobility exercises
Correct Answer: C
Rationale: Splints for footdrop are removed and reapplied every 2 hours to maintain alignment and allow skin inspection. Other schedules are not standard.
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.