Nokea
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.
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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 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.
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
- A. Reflex activity
- B. Level of consciousness
- C. Cognitive ability
- D. Sensory involvement
Correct Answer: B
Rationale: The GCS assesses level of consciousness through eye, verbal, and motor responses. It does not evaluate reflexes, cognition, or sensory function.
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
- A. Epidural hemorrhage
- B. Hypertensive emergency
- C. Spinal shock
- D. Hypovolemia
Correct Answer: C
Rationale: Spinal shock causes absent reflexes, flaccidity, and hypotension below the injury level. Other conditions do not produce this specific reflex depression.
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.