Nokea
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
- A. Risk for impaired skin integrity
- B. Risk for injury
- C. Risk for autonomic dysreflexia
- D. Risk for suffocation
Correct Answer: B
Rationale: Intubation in cervical spinal cord injury risks exacerbating the injury if the neck is flexed or extended, making 'risk for injury' the primary concern. Other diagnoses are less directly related to intubation.
You may also like to solve these questions
A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?
- A. Restrain the patient as ordered.
- B. Administer opioids PRN as ordered.
- C. Arrange for friends and family members to sit with the patient.
- D. Pad the side rails of the patients bed.
Correct Answer: D
Rationale: Padded side rails prevent self-injury without increasing ICP, unlike restraints or opioids. Visitors may not reduce agitation.
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 is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
- A. Respiratory distress and projectile vomiting
- B. Bradycardia and hypertension
- C. Tachycardia and agitation
- D. Third-spacing and hyperthermia
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.
The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
- A. Absence of pain response
- B. Apnea
- C. Coma
- D. Absence of brain stem reflexes
- E. Absence of deep tendon reflexes
Correct Answer: B,C,D
Rationale: Brain death is defined by coma, apnea, and absent brain stem reflexes. Pain response and deep tendon reflexes are not cardinal signs.
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.