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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.
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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.
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
- A. Change the patients position frequently.
- B. Provide a high-protein diet.
- C. Provide light massage at least daily.
- D. Teach the patient deep breathing and coughing exercises.
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?
- A. Hematoma
- B. Skull fracture
- C. Embolus
- D. Stroke
Correct Answer: A
Rationale: Elderly patients are at higher risk for hematomas due to adherent dura and frequent anticoagulant use. Other complications are less age-specific.
The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
- A. Help the family understand that the patient could have died.
- B. Emphasize the importance of accepting the patients new limitations.
- C. Have the members of the family plan the patients inpatient care.
- D. Assist the family in setting appropriate short-term goals.
Correct Answer: D
Rationale: Setting short-term goals helps families cope by providing achievable targets. Downplaying severity or emphasizing acceptance may not aid coping, and families cannot plan inpatient care.
The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.
- A. Young age
- B. Frequent travel
- C. African American race
- D. Male gender
- E. Alcohol or drug use
Correct Answer: A,D,E
Rationale: Young age, male gender, and substance use are major SCI risk factors. Travel and race are not significant contributors.