Nokea
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention?
- A. Urinary retention can have serious consequences in patients with SCIs.
- B. Urinary function is permanently lost following an SCI.
- C. Urinary catheters should not remain in place for more than 7 days.
- D. Overuse of urinary catheters can exacerbate nerve damage.
Correct Answer: A
Rationale: Urinary retention risks autonomic dysreflexia and trauma in SCI patients, guiding cautious catheter removal. Urinary function loss depends on injury level, and catheters do not damage nerves.
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A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.
- A. Orthostatic hypotension
- B. Autonomic dysreflexia
- C. DVT
- D. Salt-wasting syndrome
- E. Increased ICP
Correct Answer: A,B,C
Rationale: SCI patients are at risk for orthostatic hypotension, autonomic dysreflexia, and DVT due to immobility and autonomic dysfunction. Salt-wasting and increased ICP are not typical complications.
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.
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.
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 ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
- A. Epistaxis
- B. Periorbital edema
- C. Bruising over the mastoid
- D. Unilateral facial numbness
Correct Answer: C
Rationale: Bruising over the mastoid (Battle's sign) is a classic indicator of basilar skull fracture. Epistaxis, periorbital edema, and facial numbness are not specific to this injury.