Nokea
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
- A. Hyperthermia
- B. Tachycardia
- C. Hypertension
- D. Bradypnea
Correct Answer: A
Rationale: Hyperthermia indicates brain stem damage due to increased metabolic demands. Bradycardia, rising systolic BP, and rapid respirations are earlier ICP signs, while bradypnea occurs later.
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A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
- A. Check the patients indwelling urinary catheter for kinks to ensure patency.
- B. Lower the height of the bed to improve perfusion.
- C. Administer analgesia.
- D. Reassure the patient that headaches are expected after spinal cord injuries.
Correct Answer: A
Rationale: A severe headache in a C5 SCI patient suggests autonomic dysreflexia, often caused by bladder distension. Checking catheter patency is the priority action.
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 patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
- A. Placing the patient on a fluid restriction as ordered
- B. Applying thigh-high elastic stockings
- C. Administering an antifibrinolyic agent
- D. Assisting the patient with passive range of motion (PROM) exercises
Correct Answer: B
Rationale: Elastic stockings promote venous return, reducing DVT risk. Fluid restriction increases clotting risk, antifibrinolytics promote clotting, and PROM does not prevent DVT.
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.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
- A. The patient received a blood transfusion.
- B. The patients analgesia regimen was recent changed.
- C. The patient was not repositioned during the night shift.
- D. The patients urinary catheter became occluded.
Correct Answer: D
Rationale: A distended bladder from catheter occlusion is the most common trigger for autonomic dysreflexia. Other options are less likely causes.