Nokea
The nurse takes special care to be gentle in caring for patients with spinal cord injuries to avoid stimulating the autonomic nervous system and triggering which condition?
- A. Paresis
- B. Heterotopic ossification
- C. Postural hypotension
- D. Autonomic dysreflexia
Correct Answer: D
Rationale: Autonomic dysreflexia is a sudden and extreme elevation in blood pressure caused by a reflex action of the autonomic nervous system. It is the result of stimulation of the body below the level of the spinal cord injury.
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A child who was struck by a car and suffered a closed head injury was unconscious for 24 hours before waking. The nurse recognizes this as a brain injury.
Correct Answer: moderate
Rationale: A period of unconsciousness of 1 to 24 hours is characteristic of a moderate brain injury.
The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing what type of nursing?
- A. Holistic nursing
- B. Conscientious nursing
- C. Rehabilitation nursing
- D. Comprehensive nursing
Correct Answer: C
Rationale: Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable.
The rehabilitation nurse recognizes that the majority of patients with head injuries show no abnormal neurologic findings and experience no loss of consciousness. How should the nurse categorize this type of brain injury?
- A. Mild
- B. Moderate
- C. Severe
- D. Catastrophic
Correct Answer: A
Rationale: Mild brain injury is characterized by no loss of consciousness and no abnormal neurologic findings.
What should the nurse do to reduce the incidence of postural hypotension in a patient with a spinal cord injury?
- A. Monitor diastolic blood pressure closely.
- B. Encourage the patient to remain in the bed.
- C. Raise the head of the bed for 15 to 20 minutes before transfer to a wheelchair.
- D. Encourage adequate intake of fluids to expand fluid volume.
Correct Answer: C
Rationale: Raising the head of the bed before transfer allows for gradual vessel accommodation from the supine position to the upright position. It is important to check the patient's blood pressure, but it will not reduce the incidence of postural hypotension. It is important to encourage the patient to get out of bed. Postural hypotension is related to a pooling of blood in the lower extremities and is not related to a fluid volume deficit.
What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?
- A. Loud sound
- B. Distended bladder
- C. Leg cramp
- D. Sudden chilling
Correct Answer: B
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.