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

Use a draw sheet to move the patient

Have the patient grasp the side rail and assist with turning

Cross the lower extremities, turn the hips then turn the shoulders

With one person holding the head, 2 others log roll the client as a unit

Answer and Explanation

The Correct Answer is D

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

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Correct Answer is D

Explanation

A. Bradycardia is possible due to autonomic dysfunction but is not the leading cause of death.

B. Sepsis can occur due to immobility and pressure injuries but is secondary to respiratory compromise.

C. Hypertension is not directly linked to high cervical spine injuries and is less common than respiratory issues in this setting.

D. Respiratory compromise is the primary cause of complications or death in patients with a high cervical spine injury (C-3 and above) due to loss of innervation to the diaphragm and intercostal muscles, which impairs spontaneous breathing. Mechanical ventilation is often required to maintain adequate oxygenation.

A. display preinjury personality traits. B. actively participate in the rehabilitation process as appropriate. C. return to work as a corporate attorney. D. recall events from childhood.

Correct Answer is B

Explanation

A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.

B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.

C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.

D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient in the acute care setting with a spinal cord injury (SCI) at the level of C-3. What is the main cause of complications or death related to this injury?

Correct Answer is D

Explanation

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

Correct Answer is B

Explanation

The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

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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?

The healthcare provider has prescribed intravenous (IV) lorazepam for the patient in status epilepticus. During administration, which is the priority assessment by the nurse?

A patient has returned to the unit following a peripheral arteriogram. During the assessment, the nurse notes that the dorsalis pedis pulse is not palpable and the foot is cold. What should be the nurse's immediate action?

A patient is admitted to the Emergency Department (ED). The nurse documents "postictal upon transfer" as evidenced by which observation?