ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 68 : Management of Patients with Neurologic Trauma Questions
Question 1 of 5
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
Correct Answer: A
Rationale: A severe headache in a C5 SCI patient suggests autonomic dysreflexia, often caused by bladder distension. Checking catheter patency is the priority action.
Question 2 of 5
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?
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.
Question 3 of 5
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?
Correct Answer: B
Rationale: These positions promote venous drainage, reducing ICP. They do not directly affect arterial pressure, contractures, or aspiration risk.
Question 4 of 5
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
Correct Answer: A
Rationale: Spinal shock results in absent reflexes and flaccid extremities. Spasticity and hyperreflexia occur after spinal shock resolves.
Question 5 of 5
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
Correct Answer: B
Rationale: The GCS assesses level of consciousness through eye, verbal, and motor responses. It does not evaluate reflexes, cognition, or sensory function.