Brunner’s Ch 68: Management of Patients with Neurologic Trauma

Question 1

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?
A) Epistaxis
B) Periorbital edema
C) Bruising over the mastoid
D) Unilateral facial numbness

Answer 1

C) Bruising over the mastoid

An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

Question 2

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?
A) Risk for impaired skin integrity
B) Risk for injury
C) Risk for autonomic dysreflexia
D) Risk for suffocation

Answer 2

B) Risk for injury

If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

Question 3

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia

Answer 3

B) Bradycardia and hypertension

Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

Question 4

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
A) Hyperthermia
B) Tachycardia
C) Hypertension
D) Bradypnea

Answer 4

A) Hyperthermia

Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.

Question 5

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?
A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
C) Emergency craniotomy
D) Administration of anticoagulant therapy

Answer 5

C) Emergency craniotomy

An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.

Question 6

The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?

a. Prepare to transfuse packed red blood cells
b. Prepare for interventions to increase the patients BP.
c. Place the patient in the Trendelenberg position.
d. Prepare an ice bath to lower core body temperature

Answer 6

b. Prepare for interventions to increase the patients BP.

Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

Question 7

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

a. Sports-related injuries
b. Acts of violence
c. Injuries due to a fall
d. Motor vehicle accidents

Answer 7

d. Motor vehicle accidents

The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).

Question 8

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?
A) Placing the patient on a fluid restriction as ordered
B) Applying thigh-high elastic stockings
C) Administering an antifibrinolyic agent
D) Assisting the patient with passive range of motion (PROM) exercises

Answer 8

B) Applying thigh-high elastic stockings

It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

Question 9

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?
A) Keep the head of the bed (HOB) flat at all times.
B) Teach the patient to perform the Valsalva maneuver.
C) Administer benzodiazepines on a PRN basis.
D) Perform endotracheal suctioning every hour.

Answer 9

C) Administer benzodiazepines on a PRN basis.

If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP.

Question 10

A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?
A) Preparation for emergency craniotomy
B) Watchful waiting and close monitoring
C) Administration of inotropic drugs
D) Fluid resuscitation

Answer 10

B) Watchful waiting and close monitoring

Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the patient is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

Question 11

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?
A) The patient received a blood transfusion.
B) The patients analgesia regimen was recent changed.
C) The patient was not repositioned during the night shift.
D) The patients urinary catheter became occluded.

Answer 11

D) The patients urinary catheter became occluded.

A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in mediations or blood transfusions are unlikely causes.

Question 12

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?
A) Repositioning the patient every 2 hours
B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates
C) Initiating (ROM) exercises as soon as possible after the injury
D) Performing ROM exercises once a day

Answer 12

C) Initiating (ROM) exercises as soon as possible after the injury

Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the patient to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

Question 13

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?
A) Restrain the patient as ordered.
B) Administer opioids PRN as ordered.
C) Arrange for friends and family members to sit with the patient.
D) Pad the side rails of the patients bed.

Answer 13

D) Pad the side rails of the patients bed.

To protect the patient from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless patients should be avoided because these medications can depress respiration, constrict the pupils, and alter the patients responsiveness. Visitors should be limited if the patient is agitated.

Question 14

A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
A) Check the patients indwelling urinary catheter for kinks to ensure patency.
B) Lower the HOB to improve perfusion.
C) Administer analgesia.
D) Reassure the patient that headaches are expected after spinal cord injuries.

Answer 14

A) Check the patients indwelling urinary catheter for kinks to ensure patency.

A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the patients catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this patient and is not expected.

Question 15

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

a. Epidural hemorrhage
b. Hypertensive emergency
c. Spinal shock
d. Hypovolemia

Answer 15

c. Spinal shock

In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

Question 16

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?

a. To decrease cerebral arterial pressure
b. To avoid impeding venous outflow
c. To prevent flexion contractures
d. To prevent aspiration of stomach contents

Answer 16

b. To avoid impeding venous outflow

Any activity or position that impedes venous outflow from the head may contribute to increased volume inside the skull and possibly increase ICP. Cerebral arterial pressure will be affected by the balance between oxygen and carbon dioxide. Flexion contractures are not a priority at this time. Stomach contents could still be aspirated in this position.

Question 17

A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
A) Absence of reflexes along with flaccid extremities
B) Positive Babinskis reflex along with spastic extremities
C) Hyperreflexia along with spastic extremities
D) Spasticity of all four extremities

Answer 17

A) Absence of reflexes along with flaccid extremities

During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinskis reflex, hyperreflexia, and spasticity of all four extremities.

Question 18

A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement

Answer 18

B) Level of consciousness

The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

Question 19

The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
A) Absence of pain response
B) Apnea
C) Coma
D) Absence of brain stem reflexes
E) Absence of deep tendon reflexes

Answer 19

B) Apnea
C) Coma
D) Absence of brain stem reflexes

The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea. Absences of pain response and deep tendon reflexes are not necessarily indicative of brain death.

Question 20

Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
A) Complete the pin site care to decrease risk of infection.
B) Notify the neurosurgeon of the occurrence.
C) Stabilize the head in a lateral position.
D) Reattach the pin to prevent further head trauma.

Answer 20

B) Notify the neurosurgeon of the occurrence.

If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

Question 21

The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
A) Promoting adequate circulation
B) Treating the childs increased ICP
C) Assessing secondary brain injury
D) Preserving brain homeostasis

Answer 21

D) Preserving brain homeostasis

All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely secondary to the broader goal of preserving brain homeostasis.

Question 22

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
A) MRI
B) PET scan
C) X-ray
D) Ultrasound

Answer 22

A) MRI

CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

Question 23

A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
A) Diffuse axonal injury
B) Grade 1 concussion with frontal lobe involvement
C) Contusion
D) Grade 3 concussion with temporal lobe involvement

Answer 23

D) Grade 3 concussion with temporal lobe involvement

In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a grade 1 concussion does not involve loss of consciousness. Diagnostic studies may show no apparent structural sign of injury, but the duration of unconsciousness is an indicator of the severity of the concussion. Diffuse axonal injury (DAI) results from widespread shearing and rotational forces that produce damage throughout the brainto axons in the cerebral hemispheres, corpus callosum, and brain stem. In cerebral contusion, a moderate to severe head injury, the brain is bruised and damaged in a specific area because of severe acceleration-deceleration force or blunt trauma.

Question 24

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?
A) Hematoma
B) Skull fracture
C) Embolus
D) Stroke

Answer 24

A) Hematoma

Two major factors place older adults at increased risk for hematomas. First, the dura becomes more adherent to the skull with increasing age. Second, many older adults take aspirin and anticoagulants as part of routine management of chronic conditions. Because of these factors, the patients risk of a hematoma is likely greater than that of stroke, embolism, or skull fracture.

Question 25

A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?

a. When the patients condition begins to deteriorate
b. As soon as the initial assessment is made
c. At the beginning of each shift
d. When there is a clinically significant change in the patients condition

Answer 25

b. As soon as the initial assessment is made

Neurologic parameters are assessed initially and as frequently as the patients condition requires. As soon as the initial assessment is made, the use of a neurologic flowchart is started and maintained. A new chart is not begun at the start of every shift.

Question 26

The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement?
A) Administer a benzodiazepine at bedtime each night.
B) Do not disturb the patient between 2200 and 0600.
C) Cluster overnight nursing activities to minimize disturbances.
D) Ensure that the patient does not sleep during the day.

Answer 26

C) Cluster overnight nursing activities to minimize disturbances.

To allow the patient longer times of uninterrupted sleep and rest, the nurse can group nursing care activities so that the patient is disturbed less frequently. However, it is impractical and unsafe to provide no care for an 8-hour period. The use of benzodiazepines should be avoided.

Question 27

The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
A) Help the family understand that the patient could have died.
B) Emphasize the importance of accepting the patients new limitations.
C) Have the members of the family plan the patients inpatient care.
D) Assist the family in setting appropriate short-term goals.

Answer 27

D) Assist the family in setting appropriate short-term goals.

Helpful interventions to facilitate coping include providing family members with accurate and honest information and encouraging them to continue to set well-defined, short-term goals. Stating that a patients condition could be worse downplays their concerns. Emphasizing the importance of acceptance may not necessarily help the family accept the patients condition. Family members cannot normally plan a patients hospital care, although they may contribute to the care in some ways.

Question 28

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.
A) Young age
B) Frequent travel
C) African American race
D) Male gender
E) Alcohol or drug use

Answer 28

A) Young age
D) Male gender
E) Alcohol or drug use

The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. Ethnicity and travel are not risk factors.

Question 29

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
A) Ensure that the player is not moved.
B) Obtain the players vital signs, if possible.
C) Perform a rapid assessment of the players range of motion.
D) Assess the players reflexes.

Answer 29

A) Ensure that the player is not moved.

At the scene of the injury, the patient must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the patients vital signs. It would be inappropriate to test ROM or reflexes.

Question 30

The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
A) Baclofen (Lioresal)
B) Dexamethasone (Decadron)
C) Mannitol (Osmitrol)
D) Phenobarbital (Luminal)

Answer 30

A) Baclofen (Lioresal)

Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in patients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

Question 31

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?
A) Change the patients position frequently.
B) Provide a high-protein diet.
C) Provide light massage at least daily.
D) Teach the patient deep breathing and coughing exercises.

Answer 31

A) Change the patients position frequently.

Frequent position changes are among the best preventative measures against pressure ulcers. A high- protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

Question 32

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
A) Administer an IV bolus of normal saline prior to repositioning.
B) Maintain bed rest until normal BP regulation returns.
C) Monitor the patients BP before and during position changes.
D) Allow the patient to initiate repositioning.

Answer 32

C) Monitor the patients BP before and during position changes.

To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each position change. Following the patients lead may or may not help regulate BP.

Question 33

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?
A) The patient will be unable to use a wheelchair.
B) The patient will be unable to swallow food.
C) The patient will be continent of urine, but incontinent of bowel.
D) The patient will require full assistance for all aspects of elimination.

Answer 33

D) The patient will require full assistance for all aspects of elimination.

Patients with a lesion at C4 are fully dependent for elimination. The patient is dependent for feeding, but is able to swallow. The patient will be capable of using an electric wheelchair.

Question 34

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?
A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.
C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.
D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

Answer 34

A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.

The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

Question 35

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?
A) Limit the amount of assistance provided with ADLs.
B) Collaborate with the physical therapist and immobilize the patients extremities temporarily.
C) Increase the frequency of ROM exercises.
D) Educate the patient about the importance of frequent position changes.

Answer 35

C) Increase the frequency of ROM exercises.

To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The patient is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The patient must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

Question 36

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?
A) At the patients request
B) Each morning and evening
C) Every 2 hours
D) One hour prior to mobility exercises

Answer 36

C) Every 2 hours

The feet are prone to footdrop; therefore, various types of splints are used to prevent footdrop. When used, the splints are removed and reapplied every 2 hours.

Question 37

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?
A) Urinary retention can have serious consequences in patients with SCIs.
B) Urinary function is permanently lost following an SCI.
C) Urinary catheters should not remain in place for more than 7 days.
D) Overuse of urinary catheters can exacerbate nerve damage.

Answer 37

A) Urinary retention can have serious consequences in patients with SCIs.

Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.

Question 38

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.
A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT
D) Salt-wasting syndrome
E) Increased ICP

Answer 38

A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT

For a spinal cord-injured patient, based on the assessment data, potential complications that may develop include DVT, orthostatic hypotension, and autonomic dysreflexia. Salt-wasting syndrome or increased ICP are not typical complications following the immediate recovery period.

Question 39

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?
A) Position the patient in a high Fowlers position when in bed.
B) Support the knees with a pillow when the patient is in bed.
C) Perform passive ROM exercises as ordered.
D) Administer NSAIDs as ordered.

Answer 39

C) Perform passive ROM exercises as ordered.

Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the patients risk of muscle spasticity.

Question 40

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?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously

Answer 40

C) Ineffective breathing patterns related to weakness of the intercostal muscles

A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.