Nokea
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
- A. Absence of reflexes along with flaccid extremities
- B. Positive Babinskis reflex along with spastic extremities
- C. Hyperreflexia along with spastic extremities
- D. Spasticity of all four extremities
Correct Answer: A
Rationale: Spinal shock results in absent reflexes and flaccid extremities. Spasticity and hyperreflexia occur after spinal shock resolves.
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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.
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.
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 has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
- A. Ensure that the player is not moved.
- B. Obtain the players vital signs, if possible.
- C. Perform a rapid assessment of the players range of motion.
- D. Assess the players reflexes.
Correct Answer: A
Rationale: Immobilizing the patient prevents worsening of a potential SCI. Assessing vitals, ROM, or reflexes risks further injury.
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.