Nokea
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
- A. Epistaxis
- B. Periorbital edema
- C. Bruising over the mastoid
- D. Unilateral facial numbness
Correct Answer: C
Rationale: Bruising over the mastoid (Battle's sign) is a classic indicator of basilar skull fracture. Epistaxis, periorbital edema, and facial numbness are not specific to this injury.
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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.
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.
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.
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.
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.