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The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
- A. Ensure that the player is not moved.
- B. Obtain the players vital signs, if possible.
- C. Perform a rapid assessment of the players range of motion.
- D. Assess the players reflexes.
Correct Answer: A
Rationale: Immobilizing the patient prevents worsening of a potential SCI. Assessing vitals, ROM, or reflexes risks further injury.
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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 is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
- A. Epidural hemorrhage
- B. Hypertensive emergency
- C. Spinal shock
- D. Hypovolemia
Correct Answer: C
Rationale: Spinal shock causes absent reflexes, flaccidity, and hypotension below the injury level. Other conditions do not produce this specific reflex depression.
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.
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 trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
- A. Risk for impaired skin integrity
- B. Risk for injury
- C. Risk for autonomic dysreflexia
- D. Risk for suffocation
Correct Answer: B
Rationale: Intubation in cervical spinal cord injury risks exacerbating the injury if the neck is flexed or extended, making 'risk for injury' the primary concern. Other diagnoses are less directly related to intubation.