A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

Provide small doses of opioid analgesia

Maintain pCO2 of 35-45

Administer an anti-anxiety agent

Monitor blood pressure every four hours

Answer and Explanation

The Correct Answer is B

Choice A reason:

Providing small doses of opioid analgesia is important for pain management, but it is not the highest priority in a patient with a closed head injury on mechanical ventilation. Pain control should be balanced with the need to monitor neurological status.

Choice B reason:

Maintaining pCO2 of 35-45 is critical for patients with a closed head injury on mechanical ventilation. Proper pCO2 levels help manage intracranial pressure (ICP) and prevent secondary brain injury. Hyperventilation to lower pCO2 can reduce ICP but must be carefully controlled to avoid cerebral ischemia.

Choice C reason:

Administering an anti-anxiety agent can help manage agitation and anxiety, but it is not the highest priority. Sedation must be used cautiously in head injury patients to avoid masking changes in neurological status.

Choice D reason:

Monitoring blood pressure every four hours is necessary for overall patient care, but continuous monitoring and immediate interventions are more critical in managing intracranial pressure and preventing secondary brain injury.

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Correct Answer is ["B","D"]

Explanation

Choice A reason:

Increased oxygen saturation is not typically associated with neurogenic shock. Neurogenic shock usually involves bradycardia, hypotension, and potential respiratory issues, but not an increase in oxygen saturation.

Choice B reason:

Urine output less than 30 mL/hr is a sign of decreased perfusion to the kidneys, which can occur in neurogenic shock due to hypotension. This reduced urine output is a concerning manifestation that the nurse should monitor closely.

Choice C reason:

A decreased level of consciousness can be related to many factors, including hypoxia, hypotension, or other complications from the spinal cord injury. While it is an important sign to monitor, it is not a definitive marker of neurogenic shock.

Choice D reason:

A heart rate of 34 beats/min (bradycardia) is a common sign of neurogenic shock, which results from the loss of sympathetic tone due to the spinal cord injury. Bradycardia and hypotension are key indicators of neurogenic shock.

A. The extent of your injury cannot be determined until any secondary injury to the cord has resolved. B. An MRI can reveal the extent of cord damage. C. You will have normal function when spinal shock resolves and the reflex arc returns. D. Because rehabilitation can affect the return of function, it will be years before impairment can be determined.

Correct Answer is A

Explanation

Choice A reason:

The extent of impairment following a spinal cord injury cannot be determined until any secondary injury to the cord has resolved. Secondary injury, such as inflammation and swelling, can worsen the initial damage and impact the long-term prognosis.

Choice B reason:

An MRI can reveal the extent of cord damage but does not provide a complete picture of the potential functional outcomes. The full extent of impairment cannot be determined solely by imaging.

Choice C reason:

Stating that the patient will have normal function when spinal shock resolves and the reflex arc returns is misleading and overly optimistic. Not all patients will regain normal function after a spinal cord injury, and outcomes vary.

Choice D reason:

While rehabilitation plays a crucial role in recovery, stating that it will be years before impairment can be determined is not entirely accurate. Functional outcomes can often be assessed sooner as the initial recovery phase progresses.

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A nurse is caring for a patient with a closed head injury on mechanical ventilation. Which of the following actions is highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient who experienced a spinal cord injury at the T5 level 24 hours ago. Which manifestations would the nurse correlate with neurogenic shock? Select all that apply.

Correct Answer is ["B","D"]

Explanation

Immediately following a spinal cord injury, a patient asks about the extent of impairment that will result from the injury. The best response by the nurse is:

Correct Answer is A

Explanation

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