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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 C

Explanation

A. While drug dependence can be a concern with long-term use, it is not the immediate priority in an emergency setting where the goal is to stabilize the patient in status epilepticus.

B. Cardiac rhythm monitoring is important when administering certain medications, but lorazepam primarily affects the central nervous system and respiratory system, making oxygen saturation monitoring more critical.

C. Pulse oximetry is the priority assessment as IV lorazepam can depress the respiratory system, leading to hypoxia. Monitoring oxygen saturation helps ensure the patient maintains adequate respiratory function during administration.

D. Assessing pain is important in patient care, but it is not the priority in managing a patient in status epilepticus, where stabilization is essential.

A. after the client has an electroencephalogram (EEG)." B. due to having minimal risk for infection." C. by threading it through the femoral artery to the brain." D. to monitor intracranial pressure (ICP) and drain the cerebral spinal fluid."

Correct Answer is D

Explanation

A. EEG is a monitoring tool for brain activity, but it is not a prerequisite for ventriculostomy placement.

B. While the procedure is carefully managed to reduce infection risk, ventriculostomy does have an infection risk due to its invasive nature.

C. Ventriculostomy is not inserted via the femoral artery; it is placed directly in the brain’s ventricles.

D. A ventriculostomy is used to monitor ICP and allows for the drainage of cerebrospinal fluid, which helps in managing elevated ICP in patients with brain injuries.

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

Correct Answer is C

Explanation

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

Correct Answer is D

Explanation

The nurse is caring for several patients with eye disorders. Which assessment finding correlates with each diagnosis? Note: each column must have one response option selected. Note: Each category must have at least 1 response option selected.

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?

The nurse is caring for a patient in the ICU with a diagnosis of acute closed head injury whose intracranial pressure (ICP) is 30mmHg. What is the priority action by the nurse?

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?

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:

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)

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

The nurse suspects autonomic dysreflexia in the patient with a spinal cord injury at the level of C-7. After checking vital signs what are the priority nursing interventions?