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The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement?
- A. Administer a benzodiazepine at bedtime each night.
- B. Do not disturb the patient between 2200 and 0600.
- C. Cluster overnight nursing activities to minimize disturbances.
- D. Ensure that the patient does not sleep during the day.
Correct Answer: C
Rationale: Clustering nursing activities allows longer uninterrupted sleep periods, addressing sleep deprivation safely. Benzodiazepines and no disturbances are impractical or risky.
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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.
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.
A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.
- A. Orthostatic hypotension
- B. Autonomic dysreflexia
- C. DVT
- D. Salt-wasting syndrome
- E. Increased ICP
Correct Answer: A,B,C
Rationale: SCI patients are at risk for orthostatic hypotension, autonomic dysreflexia, and DVT due to immobility and autonomic dysfunction. Salt-wasting and increased ICP are not typical complications.
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.
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.