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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.
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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.
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 is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?
- A. Repositioning the patient every 2 hours
- B. Initiating range-of-motion exercises (ROM) as soon as the patient initiates
- C. Initiating (ROM) exercises as soon as possible after the injury
- D. Performing ROM exercises once a day
Correct Answer: C
Rationale: Early passive ROM exercises prevent contractures. Waiting for patient initiation or daily exercises is insufficient, and repositioning alone does not address contractures.
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.
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.