chapter 68 part 1
38. 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
28. 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 D) Male gender E) Alcohol or drug use
34. The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?
ANS: A) "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."
30. The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
ANS: A) Baclofen (Lioresal)
31. The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk?
ANS: A) Change the patient's position frequently
29. 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?
ANS: A) Ensure that the player is not moved
24. An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?
ANS: A) Hematoma
22. A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
ANS: A) MRI
37. A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?
ANS: A) Urinary retention can have serious consequences in patients with SCIs.
25. A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patient's care should the nurse begin to use a neurologic flow chart?
ANS: B) As soon as the initial assessment is made
26. The nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of "sleep deprivation." What action should the nurse implement?
ANS: C) Cluster overnight nursing activities to minimize disturbances
36. Splints have been ordered for a patient who is at risk of developing foot drop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
ANS: C) Every 2 hours
35. The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
ANS: C) Increase the frequency of ROM exercises
40. 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?
ANS: C) Ineffective breathing patterns related to weakness of the intercostal muscles
32. A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension?
ANS: C) Monitor the patient's BP before and during position changes
39. 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?
ANS: C) Perform passive ROM exercises as ordered.
27. 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?
ANS: D) Assist the family in setting appropriate short-term goals
23. 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?
ANS: D) Grade 3 concussion with temporal lobe involvement
21. The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
ANS: D) Preserving brain homeostasis
33. A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider?
ANS: D) The patient will require full assistance for all aspects of elimination
