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The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
- A. Position the patient in a high Fowlers position when in bed.
- B. Support the knees with a pillow when the patient is in bed.
- C. Perform passive ROM exercises as ordered.
- D. Administer NSAIDs as ordered.
Correct Answer: C
Rationale: Passive ROM exercises prevent muscle spasticity by maintaining flexibility. Positioning or NSAIDs do not address spasticity directly.
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An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
- A. Sports-related injuries
- B. Acts of violence
- C. Injuries due to a fall
- D. Motor vehicle accidents
Correct Answer: D
Rationale: Motor vehicle accidents account for 46% of SCIs, making them the most common cause, followed by falls, violence, and sports injuries.
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 is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
- A. Risk for impaired skin integrity related to immobility.
- B. Impaired physical mobility related to loss of motor function.
- C. Ineffective breathing patterns related to weakness of the intercostal muscles.
- D. Unable to void spontaneously due to neurogenic bladder.
Correct Answer: C
Rationale: Ineffective breathing is the priority due to C4 SCI affecting diaphragmatic and intercostal function, often requiring ventilatory support. Other diagnoses are secondary in immediate care.
The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
- A. Absence of pain response
- B. Apnea
- C. Coma
- D. Absence of brain stem reflexes
- E. Absence of deep tendon reflexes
Correct Answer: B,C,D
Rationale: Brain death is defined by coma, apnea, and absent brain stem reflexes. Pain response and deep tendon reflexes are not cardinal signs.
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.