The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

A patient who was in an assault resulting in basilar skull fracture.

A patient who was found face down in water for an unknown length of time.

A patient who suffered an epidural or subdural hematoma.

A patient who experienced prolonged seizures without regaining consciousness.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Basilar skull fractures can lead to cerebral injuries and CSF leaks, but do not typically cause anoxic brain injury unless they compromise oxygenation or cause cerebral edema severely reducing blood flow.

Choice B rationale

Prolonged submersion compromises oxygen delivery, leading to diffuse cerebral hypoxia or anoxia, the primary cause of brain injury in drowning victims due to interruption of arterial oxygenation over unknown durations.

Choice C rationale

Epidural or subdural hematomas elevate intracranial pressure and compress brain tissue, but they are not as immediately hypoxic as situations involving complete oxygen deprivation like submersion.

Choice D rationale

Prolonged seizures, or status epilepticus, may disrupt normal metabolic processes, potentially causing neuronal injury. However, primary hypoxia is generally less pronounced than in submersion cases.

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Correct Answer is C

Explanation

Choice A rationale

Sleeping on the operative side increases pressure on the eye, risking complications like increased intraocular pressure and disrupted healing of surgical incisions. Postoperative care avoids this positioning.

Choice B rationale

Lifting items over 5-10 pounds risks increased intraocular pressure. Guidelines usually limit lifting to light objects, not 30 pounds. Heavy lifting can cause strain affecting surgical recovery.

Choice C rationale

Eye shields protect the operative site during sleep, preventing accidental trauma, while glasses shield from debris during daytime. These preventive measures support proper healing and recovery post-cataract surgery.

Choice D rationale

Avoiding eye drops disrupts healing as prescribed medications manage inflammation and prevent infections after surgery. Proper use of eye drops supports post-surgical recovery effectively.

A. Nerves that control lung function have been injured. B. Patient is unable to breathe because he is unconscious. C. Accident injured the patient’s lungs. D. Patient has a history of smoking.

Correct Answer is A

Explanation

Choice A rationale

Cervical spinal cord injuries at or above C3 disrupt the phrenic nerve, impairing diaphragm control, leading to respiratory failure. Mechanical ventilation compensates for the loss of neural signals required for effective breathing.

Choice B rationale

Unconsciousness alone does not necessitate ventilation unless breathing is compromised. Here, respiratory failure stems from cervical nerve injury, not loss of consciousness, requiring mechanical support.

Choice C rationale

The lungs themselves are not damaged in cervical spinal cord injuries; the issue lies in disrupted nerve signals needed for diaphragm and respiratory muscle function, necessitating ventilatory assistance.

Choice D rationale

Smoking history does not explain the acute respiratory failure caused by cervical spinal cord injuries. The need for ventilation directly results from damage to the neural control of respiratory muscles.

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The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

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Naxlex Comprehensive Predictor Exams

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