Nokea
The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
- A. Promoting adequate circulation
- B. Treating the childs increased ICP
- C. Assessing secondary brain injury
- D. Preserving brain homeostasis
Correct Answer: D
Rationale: Preserving brain homeostasis prevents secondary brain injury and guides initial therapy. Specific ICP treatment or circulation focus is secondary.
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The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?
- A. Prepare to transfuse packed red blood cells.
- B. Prepare for interventions to increase the patients BP.
- C. Place the patient in the Trendelenberg position.
- D. Prepare an ice bath to lower core body temperature.
Correct Answer: B
Rationale: Neurogenic shock causes hypotension and bradycardia, requiring interventions to raise BP. Transfusions, Trendelenberg, and ice baths are not indicated.
The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
- A. Absence of pain response
- B. Apnea
- C. Coma
- D. Absence of brain stem reflexes
- E. Absence of deep tendon reflexes
Correct Answer: B,C,D
Rationale: Brain death is defined by coma, apnea, and absent brain stem reflexes. Pain response and deep tendon reflexes are not cardinal signs.
The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.
- A. Young age
- B. Frequent travel
- C. African American race
- D. Male gender
- E. Alcohol or drug use
Correct Answer: A,D,E
Rationale: Young age, male gender, and substance use are major SCI risk factors. Travel and race are not significant contributors.
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
- A. At the patients request
- B. Each morning and evening
- C. Every 2 hours
- D. One hour prior to mobility exercises
Correct Answer: C
Rationale: Splints for footdrop are removed and reapplied every 2 hours to maintain alignment and allow skin inspection. Other schedules are not standard.
A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
- A. Diffuse axonal injury
- B. Grade 1 concussion with frontal lobe involvement
- C. Contusion
- D. Grade 3 concussion with temporal lobe involvement
Correct Answer: D
Rationale: Grade 3 concussion with temporal lobe involvement causes prolonged unconsciousness and amnesia, with normal MRI. Grade 1 has no loss of consciousness, and DAI or contusion typically show structural damage.