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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.
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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 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.
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
- A. Reflex activity
- B. Level of consciousness
- C. Cognitive ability
- D. Sensory involvement
Correct Answer: B
Rationale: The GCS assesses level of consciousness through eye, verbal, and motor responses. It does not evaluate reflexes, cognition, or sensory function.
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.
The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
- A. Help the family understand that the patient could have died.
- B. Emphasize the importance of accepting the patients new limitations.
- C. Have the members of the family plan the patients inpatient care.
- D. Assist the family in setting appropriate short-term goals.
Correct Answer: D
Rationale: Setting short-term goals helps families cope by providing achievable targets. Downplaying severity or emphasizing acceptance may not aid coping, and families cannot plan inpatient care.