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 D

Explanation

Choice A rationale

Crossing the lower extremities and turning the hips and shoulders separately risks twisting or misalignment of the spinal column, which is contraindicated in spinal cord injury patients.

Choice B rationale

Asking the patient to assist by grasping the side rail is inappropriate as it may worsen the injury or result in unsafe movement, especially if the spinal cord is unstable.

Choice C rationale

Moving the patient independently with a draw sheet is unsafe due to the risk of misalignment or additional spinal damage, necessitating assistance and a coordinated approach.

Choice D rationale

Log rolling with one person holding the head and two others moving the body ensures spinal alignment and minimizes further injury during repositioning of spinal cord injury patients.

A. Helps determine if there has been bleeding to brain tissue. B. Checks for adequate oxygen intake by cerebral tissue. C. Will assess brain waves to see if seizure activity is still occurring.

Correct Answer is C

Explanation

Choice A rationale

While bleeding could indicate trauma, EEG does not detect blood presence or volume but instead evaluates electrical brain activity indicative of neuronal function.

Choice B rationale

Cerebral oxygen intake assessment requires pulse oximetry or arterial blood gas analysis rather than EEG, which monitors electrical signals, not oxygenation status.

Choice C rationale

EEG identifies abnormal brain wave patterns suggesting ongoing seizure activity, even in sedated patients, aiding in targeted interventions and preventing potential complications.

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Naxlex Comprehensive Predictor Exams

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

Correct Answer is D

Explanation

Correct Answer is C

Explanation

The nurse is caring for a patient with a spinal cord injury who has a flaccid or atonic bladder.The nurse would provide discharge education to the patient and family regarding which bladder management technique?

When considering the pharmacologic management of a patient who has sustained a traumatic head injury, the nurse can anticipate an order for which of the following medications to manage increases in intracranial pressure (ICP)?

A nurse is assessing a previously alert client who has now become confused, lethargic, and does not follow commands appropriately.The blood glucose measures 48 mg/dL. What is the appropriate nursing intervention?

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?

Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

The nurse is caring for a patient with epilepsy who has recently had a change in their prescribed medication combination.Which of the following options are priority to institute?

A client has a past medical history of coronary artery disease and emphysema.The nurse knows which agent is safest to give?

The nurse is reviewing discharge instructions for a patient with a spinal cord injury to T-10 going home with an indwelling urinary catheter.What would the nurse emphasize about catheter care? (Select All that Apply.)