Nokea
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.
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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.
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.
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.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
- A. Sports-related injuries
- B. Acts of violence
- C. Injuries due to a fall
- D. Motor vehicle accidents
Correct Answer: D
Rationale: Motor vehicle accidents account for 46% of SCIs, making them the most common cause, followed by falls, violence, and sports injuries.
The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
- A. Baclofen (Lioresal)
- B. Dexamethasone (Decadron)
- C. Mannitol (Osmitrol)
- D. Phenobarbital (Luminal)
Correct Answer: A
Rationale: Baclofen is an antispasmodic used for SCI-related spasticity. Dexamethasone reduces inflammation, mannitol treats cerebral edema, and phenobarbital is for seizures.