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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.
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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.
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
- A. Check the patients indwelling urinary catheter for kinks to ensure patency.
- B. Lower the height of the bed to improve perfusion.
- C. Administer analgesia.
- D. Reassure the patient that headaches are expected after spinal cord injuries.
Correct Answer: A
Rationale: A severe headache in a C5 SCI patient suggests autonomic dysreflexia, often caused by bladder distension. Checking catheter patency is the priority action.
The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
- A. Baclofen (Lioresal)
- B. Dexamethasone (Decadron)
- C. Mannitol (Osmitrol)
- D. Phenobarbital (Luminal)
Correct Answer: A
Rationale: Baclofen is an antispasmodic used for SCI-related spasticity. Dexamethasone reduces inflammation, mannitol treats cerebral edema, and phenobarbital is for seizures.
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 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.