A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

Patient with a Glasgow Coma Scale score that was 9 and is now 12.

Patient who is requesting pain medication for a new onset headache.

Patient with a Glasgow Coma Scale score that was 10 and is now 8.

Patient with a moderate brain injury who is amnesic for the event.

Answer and Explanation

The Correct Answer is C

Choice A reason:

A Glasgow Coma Scale (GCS) score that improves from 9 to 12 indicates a positive trend in the patient's neurological status. While monitoring is still required, this patient is not the highest priority.

Choice B reason:

A patient requesting pain medication for a new onset headache needs attention, but this is not as urgent as a significant decline in the Glasgow Coma Scale score, which can indicate a deterioration in neurological function.

Choice C reason:

A Glasgow Coma Scale score that drops from 10 to 8 signifies a significant decline in the patient's neurological status, indicating potential worsening of the condition. This patient requires immediate assessment and intervention to identify and address the cause of the deterioration.

Choice D reason:

A patient with a moderate brain injury who is amnesic for the event needs ongoing monitoring, but this is not as urgent as addressing a significant drop in the Glasgow Coma Scale score.

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Correct Answer is B

Explanation

Choice A reason:

Young adults ages 12-20 are at risk for spinal cord injuries due to sports and recreational activities. However, the highest risk group for spinal cord injuries, particularly from activities such as motor vehicle accidents and risky behaviors, is young men ages 16-30.

Choice B reason:

Young men ages 16-30 are the highest risk group for spinal cord injuries. This population is more likely to engage in high-risk activities such as driving, contact sports, and recreational activities that can lead to spinal cord injuries. Therefore, they would benefit most from targeted prevention education.

Choice C reason:

Children ages 2-15 are at risk for spinal cord injuries, particularly from falls and accidents. However, their risk is lower compared to the young adult male population. Education for this group is important but not as critical as for young men.

Choice D reason:

Elderly people ages 60 and up are at risk for spinal cord injuries, primarily from falls. While prevention education is important for this group, they are not the highest risk population compared to young men ages 16-30.

A. Palpate the bladder for distention. B. Initiate oxygen via a nasal cannula. C. Place the patient in a supine position. D. Administer a prescribed beta-blocker.

Correct Answer is A

Explanation

Choice A reason:

Palpating the bladder for distention is the first action the nurse should take. The patient's symptoms suggest autonomic dysreflexia, a condition that can be triggered by bladder distention. Relieving the distention can help resolve the hypertensive crisis.

Choice B reason:

Initiating oxygen via a nasal cannula may be necessary if the patient is experiencing respiratory distress, but it is not the primary intervention for autonomic dysreflexia. The focus should be on identifying and resolving the triggering cause.

Choice C reason:

Placing the patient in a supine position is contraindicated in autonomic dysreflexia as it can worsen the condition by further increasing blood pressure. The patient should be positioned upright if tolerated.

Choice D reason:

Administering a prescribed beta-blocker may help lower blood pressure, but it is not the first action. The underlying cause of autonomic dysreflexia must be addressed to prevent recurrence.

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A nurse is caring for four patients in the neurologic intensive care unit. After receiving the hand-off report, which patient does the nurse see first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

As a community health nurse, you are planning to conduct an education session on prevention strategies for spinal cord injuries. Which population would benefit most from this education?

Correct Answer is B

Explanation

A nurse assesses a patient with a spinal cord injury at level T5. The patient's blood pressure is 184/95 mm Hg, and the patient presents with a flushed face and blurred vision. What action would the nurse take first in response to this complication?

Correct Answer is A

Explanation

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