chapter 68 part 2

13. A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

ANS: D) Pad the side rails of the patient's bed.

12. A patient is admitted to the Neuro ICU with a spinal cord injury. In writing the care plan the nurse plans that contractures can be prevented by what?

ANS: C) Initiating range-of-motion exercises 48 hours after the injury

17. A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

ANS: A) Absence of reflexes along with flaccid extremities

14. A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the intensive care unit, the patient complains of a severe throbbing headache. What should the nurse do first?

ANS: A) Check the patient's indwelling urinary catheter for kinks to ensure patency

4. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

ANS: A) Hyperthermia

8. A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

ANS: B) Applying thigh-high elastic stockings

10. A patient who has sustained a basal skull fracture is admitted to your unit. You know that the patient should be observed for what?

ANS: B) Bleeding from the ears

3. A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient

ANS: B) Bradycardia and hypertension

18. A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patient's status

ANS: B) Level of consciousness

20. 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?

ANS: B) Notify the neurosurgeon of the occurrence

6. 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 nurse's most appropriate action?

ANS: B) Prepare for interventions to increase the patient's BP

2. A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ 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?

ANS: B) Risk for injury

16. An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

ANS: B) To avoid impeding venous outflow

9. The Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what?

ANS: C) Administer antipyretics on a prn basis

1. 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?

ANS: C) Bruising over the mastoid

5. A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

ANS: C) Emergency craniotomy

15. 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?

ANS: C) Spinal shock

11. A patient has suffered a spinal cord injury. These patients are prone to having an exaggerated autonomic response triggered by what stimuli?

ANS: D) Constipation

7. 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?

ANS: D) Motor vehicle accidents

19. The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply

B) Apnea C) Coma D) Absence of brain stem reflexes