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
The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of risk for impaired skin integrity. How can the nurse best address this risk?
Correct Answer: A
Rationale: Frequent position changes prevent pressure ulcers in SCI patients. Diet, massage, and breathing exercises do not directly address skin integrity.
Question 2 of 5
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
Correct Answer: C
Rationale: Monitoring BP during position changes helps manage orthostatic hypotension. Boluses are impractical, bed rest carries risks, and patient-initiated changes may not prevent hypotension.
Question 3 of 5
A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?
Correct Answer: D
Rationale: C4 SCI causes dependency for elimination due to loss of voluntary control. Patients can use electric wheelchairs and swallow food, and continence is not preserved.
Question 4 of 5
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?
Correct Answer: A
Rationale: Autonomic dysreflexia's hypertensive crisis risks cerebral hemorrhage or increased ICP, making it an emergency. It does not directly damage nerves or increase muscle tone.
Question 5 of 5
The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
Correct Answer: C
Rationale: Increasing ROM exercise frequency prevents disuse syndrome by maintaining joint mobility. Limiting ADLs or immobilizing extremities worsens disuse, and education alone is insufficient.