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
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 2 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 3 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 4 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.
Question 5 of 5
A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?
Correct Answer: D
Rationale: Padded side rails prevent self-injury without increasing ICP, unlike restraints or opioids. Visitors may not reduce agitation.