Nokea
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.
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The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
- A. Epistaxis
- B. Periorbital edema
- C. Bruising over the mastoid
- D. Unilateral facial numbness
Correct Answer: C
Rationale: Bruising over the mastoid (Battle's sign) is a classic indicator of basilar skull fracture. Epistaxis, periorbital edema, and facial numbness are not specific to this injury.
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
- A. At the patients request
- B. Each morning and evening
- C. Every 2 hours
- D. One hour prior to mobility exercises
Correct Answer: C
Rationale: Splints for footdrop are removed and reapplied every 2 hours to maintain alignment and allow skin inspection. Other schedules are not standard.
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 neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?
- A. When the patients condition begins to deteriorate
- B. As soon as the initial assessment is made
- C. At the beginning of each shift
- D. When there is a clinically significant change in the patients condition
Correct Answer: B
Rationale: A neurologic flow chart starts with the initial assessment to track changes consistently. It is not limited to deterioration or shift changes.
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.