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 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 2 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.
Question 3 of 5
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.
Correct Answer: B,C,D
Rationale: Brain death is defined by coma, apnea, and absent brain stem reflexes. Pain response and deep tendon reflexes are not cardinal signs.
Question 4 of 5
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?
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.
Question 5 of 5
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?
Correct Answer: D
Rationale: Preserving brain homeostasis prevents secondary brain injury and guides initial therapy. Specific ICP treatment or circulation focus is secondary.