ATI LPN
Brunner & Suddarth's Textbook of Medical-Surgical Nursing 14e (Hinkle 2017)
Chapter 68 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
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 3 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 4 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 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.