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 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 2 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.
Question 3 of 5
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
Correct Answer: C
Rationale: Bruising over the mastoid (Battle's sign) is a classic indicator of basilar skull fracture. Epistaxis, periorbital edema, and facial numbness are not specific to this injury.
Question 4 of 5
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
Correct Answer: B
Rationale: Intubation in cervical spinal cord injury risks exacerbating the injury if the neck is flexed or extended, making 'risk for injury' the primary concern. Other diagnoses are less directly related to intubation.
Question 5 of 5
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
Correct Answer: B
Rationale: Autonomic dysreflexia presents with bradycardia, hypertension, headache, sweating, and nasal congestion due to sympathetic stimulation above T6. Other symptoms listed are not characteristic.