Nokea
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.
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The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.
- A. Young age
- B. Frequent travel
- C. African American race
- D. Male gender
- E. Alcohol or drug use
Correct Answer: A,D,E
Rationale: Young age, male gender, and substance use are major SCI risk factors. Travel and race are not significant contributors.
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
- A. Keep the head of the bed (HOB) flat at all times.
- B. Teach the patient to perform the Valsalva maneuver.
- C. Administer benzodiazepines on a PRN basis.
- D. Perform endotracheal suctioning every hour.
Correct Answer: C
Rationale: Benzodiazepines control agitation without raising ICP. HOB should be elevated, Valsalva and frequent suctioning increase ICP.
Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
- A. Complete the pin site care to decrease risk of infection.
- B. Notify the neurosurgeon of the occurrence.
- C. Stabilize the head in a lateral position.
- D. Reattach the pin to prevent further head trauma.
Correct Answer: B
Rationale: A detached halo pin requires immediate neurosurgeon notification to prevent injury. Stabilizing the head in neutral, not lateral, position is secondary, and reattaching or cleaning is unsafe.
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.
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.