Nokea
The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first?
- A. The client with an open head injury
- B. The client with a basilar fracture
- C. The client with a concussion
- D. The client with a coup injury
Correct Answer: B
Rationale: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.
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A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?
- A. The client is a heart transplant recipient.
- B. The client's medications include warfarin (Coumadin).
- C. The client is HIV positive.
- D. The client has a history of concussions from playing hockey.
Correct Answer: B
Rationale: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.
The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
- A. Cervical collar
- B. Cast
- C. Traction with weights and pulleys
- D. Turning frame
Correct Answer: C
Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
- A. Acetaminophen may be administered for aches.
- B. Observe for any signs of behavioral changes.
- C. A light meal may be eaten if desired.
- D. Follow up with regular physician is encouraged.
Correct Answer: B
Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.
A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of stem cell transplantation therapy. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. Cells in the spinal cord may regenerate spontaneously when injured.
- B. Stem cells can cause the damaged spinal nerves to repair themselves.
- C. Stems cells can be harvested from an individual's own bone marrow.
- D. Harvested stem cells can be reimplanted into the area surrounding the injury.
- E. Stem cells can replace the damaged nerve cells when they are transplanted.
Correct Answer: C,D,E
Rationale: When teaching the client about the benefits of stem cell transplantation therapy, the nurse should explain how stem cells are used to treat a spinal cord injury. In particular, the education should emphasize that stem cells are harvested from the client's own bone marrow and can be reimplanted into the area surrounding the injury, replacing the damaged nerve cells when they are transplanted. The spinal cord loses the ability to regenerate when injured, and stem cells replace the injured spinal nerves rather than causing them to repair themselves, so the nurse would be incorrect to include these statements when discussing the therapy with the client.
The nurse is caring for a client with impaired physical mobility who has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in this client?
- A. Provide a well-balanced diet.
- B. Position the client.
- C. Keep the client hydrated.
- D. Help the client perform exercises.
Correct Answer: C
Rationale: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony.