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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Padded tongue blades to prevent injury in the event of seizure

Soft wrist restraints to prevent injury

Ambu bag and oxygen connection for respiratory distress

Wrenches for emergency removal of traction equipment

Oral suction tube (Yankaur) for secretion removal

Answer and Explanation

Correct Answer : C,D,E

A. Padded tongue blades are not appropriate for seizure management and are not necessary in this context.

B. Soft wrist restraints are not required in this scenario unless otherwise indicated.

C. An Ambu bag and oxygen are crucial for respiratory support, especially if the patient has compromised breathing due to spinal cord injury.

D. Wrenches should be readily available to quickly remove halo traction in case of an emergency, such as if the patient's airway needs to be accessed.

E. An oral suction tube (Yankauer) is important for managing oral secretions, which can be challenging for patients with limited mobility.

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Correct Answer is A

Explanation

A. A patient found facedown in water is at high risk of anoxic brain injury due to potential prolonged oxygen deprivation, which is directly associated with lack of oxygen to the brain.

B. Multiple concussions can lead to other types of brain injury but are less associated with anoxic injury than prolonged oxygen deprivation.

C. A basilar skull fracture can cause complications such as CSF leaks but does not directly cause an anoxic brain injury.

D. An epidural hematoma may increase ICP, but with timely intervention, anoxic injury may be avoided; anoxic brain injury is more directly related to oxygen deprivation.

A. "Use a cane or walker when you begin to have difficulty walking." B. "Adjust the dose depending upon observed seizure activity." C. "You will need to have blood levels drawn annually." D. "Be sure to have regular visits to the dentist."

Correct Answer is D

Explanation

A. While using a cane or walker may be necessary for some patients experiencing balance issues, it is not a specific instruction related to phenytoin.

B. Phenytoin dosages should not be adjusted solely based on observed seizure activity; the dose must be managed carefully based on serum drug levels and the clinician's guidance.

C. Patients on phenytoin typically require more frequent monitoring of blood levels (every 2-3 months initially) rather than annually, as maintaining therapeutic levels is essential to avoid toxicity or ineffective seizure control.

D. Regular dental visits are crucial for patients taking phenytoin because the medication can cause gingival hyperplasia (overgrowth of gum tissue), which necessitates careful dental hygiene and regular monitoring by a dentist to prevent complications.

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The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for several patients in the Intensive Care Unit. Which of the following patients is at greatest risk of anoxic brain injury? A patient who:

Correct Answer is A

Explanation

The nurse is caring for a patient who was given a new medical prescription for phenytoin. What would the nurse stress in the discharge instructions regarding this medication?

Correct Answer is D

Explanation

The nurse is caring for a patient who suffered a spinal cord injury (SCI) who has had halo traction placed for spinal immobilization. What emergency equipment should the nurse have at the bedside? (SELECT ALL THAT APPLY)

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