The nurse is caring for a patient who has a spinal cord injury at the level of C-6. The patient displays the following symptoms: loss of motor function on the ipsilateral side of the injury, loss of temperature and pain sensation on the contralateral side. What type of injury did this individual most likely suffer?

Posterior cord injury

Anterior cord injury

Central cord injury

Brown-Sequard injury

Answer and Explanation

The Correct Answer is D

A. Posterior cord injury usually affects proprioception rather than causing a distinctive pattern of motor and sensory loss.

B. Anterior cord injury generally impacts motor function and temperature and pain sensation bilaterally, not in a hemisection pattern.

C. Central cord injury primarily affects motor function in the upper extremities and is not characterized by ipsilateral motor and contralateral sensory loss.

D. Brown-Sequard syndrome typically presents with motor function loss on the same (ipsilateral) side of the injury and loss of pain and temperature sensation on the opposite (contralateral) side, making this the most likely diagnosis.

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Correct Answer is C

Explanation

A. Reorienting confused patients is important but is not directly related to cerebellar injury.

B. While turning every 2 hours is important to prevent pressure injuries, it does not address the specific fall risk associated with cerebellar damage.

C. The cerebellum is responsible for balance and coordination, so injuries in this area increase the risk of falls. Ensuring the bed alarm is on provides immediate alerts if the patient attempts to get out of bed, helping to prevent falls.

D. Varying the schedule to prevent boredom is not a priority in the care of patients with cerebellar injury.

A. Drug dependence B. Cardiac rhythm C. Pulse oximetry D. Pain level

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.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with a brain injury to the cerebellum. Which nursing intervention is priority?

Correct Answer is C

Explanation

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 the first person on the scene of a motor vehicle crash. The victim was the driver and is in the driver's seat unconscious. The driver is breathing, has a pulse, and has minor lacerations on the head and face. What action should the nurse implement first?

The nurse teaches a patient diagnosed with Bell's Palsy about the use of an eye patch to prevent which eye complication?

The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

Which behavior(s) by the patient diagnosed with a chronic head injury would the nurse expect to find?

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:

The nurse is caring for a patient with an acute brain injury. Which of the following sets of vital signs would concern the nurse about increasing intracranial pressure (ICP)?

Which statement made by a patient who is diagnosed with human immunodeficiency virus (HIV) and is prescribed three antiretroviral medications, indicates the need for further teaching about the medication combination?

The nurse is caring for a patient diagnosed with unstable angina who is prescribed metoprolol. The patient asks the nurse, "Why do I have to take this medication?" What response by the nurse is most accurate?