Nokea
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
- A. Change the patients position frequently.
- B. Provide a high-protein diet.
- C. Provide light massage at least daily.
- D. Teach the patient deep breathing and coughing exercises.
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
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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 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 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.
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.
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.