The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Initiating an IV access peripherally

Maintaining an open airway using the head tilt method

Determining whether the patient is oriented to person, place, and time

Applying a rigid cervical collar and using a backboard to transport the patient

Answer and Explanation

The Correct Answer is D

A. IV access is important for fluid administration but does not prevent further spinal injury.
B. The head tilt method can worsen a cervical spine injury; instead, a jaw-thrust maneuver should be used to open the airway without neck movement.
C. Assessing orientation is part of the neurological exam but does not prevent further injury.
D. Applying a rigid cervical collar and using a backboard immobilizes the spine, preventing further spinal cord damage during transport.

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Correct Answer is A

Explanation

A.. Keeping the neck in midline and avoiding excessive hip flexion helps promote venous drainage from the brain, reducing the risk of increased intracranial pressure (ICP).
B. Incorrect. While comfort is important, the primary rationale is related to ICP management, not just comfort.
C. Restoring neutral joint position is not the main concern in postcraniotomy care regarding neck and hip positioning.
D. Preventing blood clots is related to mobility and circulation but not directly related to neck and hip positioning in this context.

A. Decorticate Posturing B. Epileptic Seizure C. Decerebrate Posturing D. Stroke

Correct Answer is A

Explanation

A. Decorticate posturing is characterized by flexion of the arms, wrists, and fingers, along with adduction of the upper extremities, and is typically a sign of damage to the cerebral hemispheres.
B. Epileptic seizures involve abnormal electrical activity in the brain and present with convulsions or altered consciousness, not specific posturing.
C. Decerebrate posturing involves extension of the arms and legs and is usually a sign of more severe brainstem damage.
D. A stroke can lead to various neurologic deficits but does not specifically describe this type of posturing.

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The nurse assists with the prehospital care of a patient who experienced a 15-foot fall. Which action by the nurse will limit the damage if a spinal cord injury (SCI) has occurred?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

You keep a postcraniotomy patient's neck in midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that this position:

Correct Answer is A

Explanation

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

Correct Answer is A

Explanation

Which position would the nurse utilize when repositioning a patient who has an increased intracranial pressure (ICP)?

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When planning the care for a patient with an increased intracranial pressure (ICP), which interventions would the nurse integrate to provide the most comfort? Select all that apply. (Select All that Apply.)