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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 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?
Correct Answer: B
Rationale: Elastic stockings promote venous return, reducing DVT risk. Fluid restriction increases clotting risk, antifibrinolytics promote clotting, and PROM does not prevent DVT.
Question 2 of 5
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
Correct Answer: C
Rationale: Benzodiazepines control agitation without raising ICP. HOB should be elevated, Valsalva and frequent suctioning increase ICP.
Question 3 of 5
A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?
Correct Answer: B
Rationale: Nondepressed skull fractures typically require observation, not surgery, inotropes, or fluid resuscitation.
Question 4 of 5
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
Correct Answer: D
Rationale: A distended bladder from catheter occlusion is the most common trigger for autonomic dysreflexia. Other options are less likely causes.
Question 5 of 5
A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?
Correct Answer: C
Rationale: Early passive ROM exercises prevent contractures. Waiting for patient initiation or daily exercises is insufficient, and repositioning alone does not address contractures.