Nokea
The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
- A. Limit the amount of assistance provided with ADLs.
- B. Collaborate with the physical therapist and immobilize the patients extremities temporarily.
- C. Increase the frequency of ROM exercises.
- D. Educate the patient about the importance of frequent position changes.
Correct Answer: C
Rationale: Increasing ROM exercise frequency prevents disuse syndrome by maintaining joint mobility. Limiting ADLs or immobilizing extremities worsens disuse, and education alone is insufficient.
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A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?
- A. Insertion of an intracranial monitoring device
- B. Treatment with antihypertensives
- C. Emergency craniotomy
- D. Administration of anticoagulant therapy
Correct Answer: C
Rationale: Epidural hematoma is a surgical emergency requiring craniotomy to remove the clot and control bleeding. Anticoagulants are contraindicated, and monitoring or antihypertensives are not priorities.
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.
A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?
- A. Preparation for emergency craniotomy
- B. Watchful waiting and close monitoring
- C. Administration of inotropic drugs
- D. Fluid resuscitation
Correct Answer: B
Rationale: Nondepressed skull fractures typically require observation, not surgery, inotropes, or fluid resuscitation.
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.
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?
- A. Hematoma
- B. Skull fracture
- C. Embolus
- D. Stroke
Correct Answer: A
Rationale: Elderly patients are at higher risk for hematomas due to adherent dura and frequent anticoagulant use. Other complications are less age-specific.