A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

Autonomic dysreflexia

Ischemia

Edema

Axial loading

Hemorrhage

Answer and Explanation

Correct Answer : A,B,C,E

Choice A reason:

Autonomic dysreflexia is a serious condition that can occur in individuals with spinal cord injuries, particularly those at or above the T6 level. It is a secondary injury mechanism that results from the autonomic nervous system's abnormal response to stimuli below the level of injury, leading to severe hypertension and other complications.

Choice B reason:

Ischemia, or reduced blood flow, is a common cause of secondary injury following a spinal cord injury. It can result from initial trauma or subsequent swelling and vascular damage, leading to further cell death and tissue damage.

Choice C reason:

Edema, or swelling, is another cause of secondary injury in spinal cord injuries. The inflammatory response to injury can cause fluid accumulation, increasing pressure within the spinal column and exacerbating damage to spinal cord tissues.

Choice D reason:

Axial loading is a primary mechanism of spinal cord injury, not a secondary injury cause. It refers to the vertical force applied along the axis of the spine, typically resulting from falls or direct blows, leading to compression and potential fractures.

Choice E reason:

Hemorrhage, or bleeding, is a significant cause of secondary injury in spinal cord trauma. It can result from blood vessel damage at the injury site, leading to increased pressure, further tissue damage, and impaired blood flow.

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Correct Answer is B

Explanation

Choice A reason:

A temperature of 96.8°F is within the normal range for a human body (97.8°F to 99.1°F). However, it does not necessarily indicate the desired effect of Dopamine. Dopamine is primarily used to improve blood flow and cardiac output, particularly in critically ill patients. Therefore, temperature alone is not a reliable indicator of its effectiveness.

Choice B reason:

Blood pressure of 110/68 mmHg suggests that the Dopamine is effectively maintaining the patient's hemodynamic stability. Dopamine is often used to support blood pressure in patients with hypotension, particularly after spinal cord injuries. Maintaining an adequate blood pressure ensures that vital organs receive sufficient blood flow, which is a key therapeutic goal of Dopamine administration.

Choice C reason:

A respiratory rate of 20 breaths/min is considered normal for an adult (12-20 breaths/min). While normal respiratory rate is a positive sign, it is not a direct measure of Dopamine's effectiveness. Dopamine's primary action is on the cardiovascular system, so a normal respiratory rate alone does not necessarily indicate that the drug is having the desired effect.

Choice D reason:

A heart rate of 70 beats/min is within the normal range for adults (60-100 beats/min). Similar to the respiratory rate, while a normal heart rate is beneficial, it is not a direct indicator of Dopamine's effectiveness. Dopamine's role in improving cardiac output and blood pressure is more critical in assessing its desired effects.

A. A 72-year-old client with a brain tumor, GCS of 5 and decerebrate posturing. B. A 24-year-old client after a motor vehicle accident with a Glasgow Coma Scale (GCS) of 3 and no activity on electroencephalogram. C. A 68-year-old male admitted with a massive stroke and GCS of 6. D. A 50-year-old female client after a motor vehicle accident and surgical evacuation of an epidural hematoma, Glasgow Coma Scale 12.

Correct Answer is B

Explanation

Choice A reason:

A 72-year-old client with a brain tumor, GCS of 5, and decerebrate posturing may not be an ideal candidate for organ donation due to age and underlying cancer, which can affect organ viability.

Choice B reason:

A 24-year-old client after a motor vehicle accident with a GCS of 3 and no activity on electroencephalogram is a prime candidate for organ donation. The lack of brain activity indicates brain death, and the patient's young age and otherwise healthy organs make them suitable for transplantation.

Choice C reason:

A 68-year-old male with a massive stroke and GCS of 6 has significant neurological impairment but is not necessarily brain dead. Further evaluation would be required, but this patient may not meet the criteria for brain death necessary for organ donation.

Choice D reason:

A 50-year-old female with a GCS of 12 after surgical evacuation of an epidural hematoma is not an ideal candidate for organ donation at this time as they have a higher level of consciousness and potential for recovery.

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A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

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Naxlex Comprehensive Predictor Exams

The physician has ordered Dopamine for a patient in the ICU who has suffered a spinal cord injury. The nurse determines that the drug is having the desired effect when the assessment findings are:

Correct Answer is B

Explanation

A charge nurse is reviewing the status of patients in the critical care unit. Which patient should the charge nurse notify the organ procurement team to evaluate for possible organ donation?

Correct Answer is B

Explanation

A nurse in the ED is assessing a client who is taking warfarin and experiencing rectal bleeding. Which of the following drugs should the nurse anticipate administering to the client?

A nursing student studying spinal cord injury recognizes all of the following to be causes of secondary injuries:

The nurse receives new orders for multiple clients. Which order should be the nurse's priority?

The nurse is caring for a patient who is on mechanical ventilation and the high pressure alarm is sounding. Which of the following is the most likely cause?

The nurse is managing a donor patient six hours prior to the scheduled harvesting of the patient's organs. Which assessment finding requires immediate action by the nurse?

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?

A nurse is caring for a client in acute respiratory failure who is receiving mechanical ventilation. Which of the following assessments is the best method to determine the effectiveness of the current treatments?

The nurse is caring for a mechanically ventilated spinal cord injury patient in the ICU. To avoid the complication of autonomic dysreflexia, the nurse plans to implement the following orders: