Nokea
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.
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Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
- A. Keep the head of the bed (HOB) flat at all times.
- B. Teach the patient to perform the Valsalva maneuver.
- C. Administer benzodiazepines on a PRN basis.
- D. Perform endotracheal suctioning every hour.
Correct Answer: C
Rationale: Benzodiazepines control agitation without raising ICP. HOB should be elevated, Valsalva and frequent suctioning increase ICP.
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.
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.
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.
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
- A. To decrease cerebral arterial pressure
- B. To avoid impeding venous outflow
- C. To prevent flexion contractures
- D. To prevent aspiration of stomach contents
Correct Answer: B
Rationale: These positions promote venous drainage, reducing ICP. They do not directly affect arterial pressure, contractures, or aspiration risk.