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A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
- A. Administer an IV bolus of normal saline prior to repositioning.
- B. Maintain bed rest until normal BP regulation returns.
- C. Monitor the patients BP before and during position changes.
- D. Allow the patient to initiate repositioning.
Correct Answer: C
Rationale: Monitoring BP during position changes helps manage orthostatic hypotension. Boluses are impractical, bed rest carries risks, and patient-initiated changes may not prevent hypotension.
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A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
- A. Risk for impaired skin integrity related to immobility.
- B. Impaired physical mobility related to loss of motor function.
- C. Ineffective breathing patterns related to weakness of the intercostal muscles.
- D. Unable to void spontaneously due to neurogenic bladder.
Correct Answer: C
Rationale: Ineffective breathing is the priority due to C4 SCI affecting diaphragmatic and intercostal function, often requiring ventilatory support. Other diagnoses are secondary in immediate care.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
- A. Complete the pin site care to decrease risk of infection.
- B. Notify the neurosurgeon of the occurrence.
- C. Stabilize the head in a lateral position.
- D. Reattach the pin to prevent further head trauma.
Correct Answer: B
Rationale: A detached halo pin requires immediate neurosurgeon notification to prevent injury. Stabilizing the head in neutral, not lateral, position is secondary, and reattaching or cleaning is unsafe.
A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
- A. Diffuse axonal injury
- B. Grade 1 concussion with frontal lobe involvement
- C. Contusion
- D. Grade 3 concussion with temporal lobe involvement
Correct Answer: D
Rationale: Grade 3 concussion with temporal lobe involvement causes prolonged unconsciousness and amnesia, with normal MRI. Grade 1 has no loss of consciousness, and DAI or contusion typically show structural damage.
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.
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?
- A. The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
- B. The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.
- C. Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.
- D. The sudden, severe headache increases muscle tone and can cause further nerve damage.
Correct Answer: A
Rationale: Autonomic dysreflexia's hypertensive crisis risks cerebral hemorrhage or increased ICP, making it an emergency. It does not directly damage nerves or increase muscle tone.