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
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
Correct Answer: C
Rationale: Splints for footdrop are removed and reapplied every 2 hours to maintain alignment and allow skin inspection. Other schedules are not standard.
Question 2 of 5
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention?
Correct Answer: A
Rationale: Urinary retention risks autonomic dysreflexia and trauma in SCI patients, guiding cautious catheter removal. Urinary function loss depends on injury level, and catheters do not damage nerves.
Question 3 of 5
A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.
Correct Answer: A,B,C
Rationale: SCI patients are at risk for orthostatic hypotension, autonomic dysreflexia, and DVT due to immobility and autonomic dysfunction. Salt-wasting and increased ICP are not typical complications.
Question 4 of 5
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
Correct Answer: C
Rationale: Passive ROM exercises prevent muscle spasticity by maintaining flexibility. Positioning or NSAIDs do not address spasticity directly.
Question 5 of 5
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
Correct Answer: C
Rationale: Ineffective breathing is the priority due to C4 SCI affecting diaphragmatic and intercostal function, often requiring ventilatory support. Other diagnoses are secondary in immediate care.