Nokea
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
- A. Keep the head of the bed (HOB) flat at all times.
- B. Teach the patient to perform the Valsalva maneuver.
- C. Administer benzodiazepines on a PRN basis.
- D. Perform endotracheal suctioning every hour.
Correct Answer: C
Rationale: Benzodiazepines control agitation without raising ICP. HOB should be elevated, Valsalva and frequent suctioning increase ICP.
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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 caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
- A. Respiratory distress and projectile vomiting
- B. Bradycardia and hypertension
- C. Tachycardia and agitation
- D. Third-spacing and hyperthermia
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.
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.
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
- A. Change the patients position frequently.
- B. Provide a high-protein diet.
- C. Provide light massage at least daily.
- D. Teach the patient deep breathing and coughing exercises.
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
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.