Spinal Cord Injury Ch.68 E2

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? a) Alcohol/drug use b) Male gender c) Being an athlete d) Young age

Being an athlete Explanation: The predominant risk factors for SCI include young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use.

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. a) Eye opening b) Muscle strength c) Verbal response d) Intelligence e) Motor response

• Eye opening • Verbal response • Motor response Correct Explanation: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

A patient arrives at the ED via ambulance following a motor cycle accident. The paramedics state the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS score is 7. The nurse anticipates which of the following? a) An order for a head CT scan b) Intubation and mechanical ventilation c) Immediate craniotomy d) Administration of propofol (Diprivan) IV

Immediate craniotomy Explanation: The patient is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease ICP emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During this lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? a) Watch closely for signs of urinary tract infection. b) Keep accurate intake and output. c) Maintain a diet for the client that is high in protein, vitamins, and calories. d) Avoid range of motion exercises for the client because of spasms.

Maintain a diet for the client that is high in protein, vitamins, and calories. Explanation: To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

Which of the following is the most common cause of spinal cord injury (SCI)? a) Sports-related injuries b) Motor vehicle crashes c) Falls d) Acts of violence

Motor vehicle crashes Correct Explanation: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI.