A 21-year-old male was admitted to the emergency department following a high-speed motorcycle accident.
He was reported to be unconscious at the scene, but upon arrival he was awake and oriented with a Glasgow Coma Scale (GCS) of 15. Suddenly, he becomes unconscious and mental status deteriorates to a GCS of 8. The nurse anticipates which of the following injuries?

Subarachnoid hemorrhage.

Diffuse axonal injury.

Epidural hematoma.

Subdural hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.

Choice B rationale

Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.

Choice C rationale

Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.

Choice D rationale

Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .

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Correct Answer is C

Explanation

Choice A rationale

Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.

Choice B rationale

Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.

Choice C rationale

Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.

Choice D rationale

Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.

A. Hypertension. B. Bradycardia. C. Sepsis. D. Respiratory compromise.

Correct Answer is D

Explanation

Choice A rationale

Hypertension is not the primary concern in cervical spinal cord injuries at C-3, where respiratory compromise due to diaphragm paralysis is the leading cause of complications or mortality.

Choice B rationale

Bradycardia can occur due to vagal stimulation in spinal injuries but is less life-threatening compared to the respiratory compromise caused by diaphragmatic paralysis.

Choice C rationale

Sepsis may develop in spinal cord injury patients, particularly from infections like pneumonia or urinary tract infections, but respiratory failure is the most acute concern at C-3.

Choice D rationale

Respiratory compromise occurs due to impaired diaphragm function at C-3, making it the primary cause of morbidity or mortality, necessitating prompt respiratory support and monitoring.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient who had a serious head injury.The patient has recovered enough to be transferred to a rehabilitation facility.Which of the following rehabilitation goals would be most appropriate for the patient?

Correct Answer is C

Explanation

The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

Correct Answer is D

Explanation

The nurse is educating on the placement of a ventriculostomy (intraventricular catheter) to the family of a patient diagnosed with a brain injury.The nurse states, "The ventriculostomy is placed:

The nurse is performing an admission assessment on a client with a diagnosis of detached retina.Which of the following is associated with this eye disorder?

The nurse knows that an important contraindication for valproic acid use is:

The client who is diagnosed with a seizure disorder is prescribed a ketogenic diet.The nurse knows that the client understands the teaching when they state:

The client is being discharged from the ambulatory care unit following cataract removal.The nurse provides instructions regarding home care.Which of the following, if stated by the client, indicates an understanding of the instructions?

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:

The nurse is preparing to turn the patient who sustained a spinal cord injury.How should the nurse proceed?

A client with a severe stroke has been prescribed enteral feedings via a jejunostomy tube.For safe administration, the nurse should: