The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Soak the pin sites with alcohol pads

Remove the vest when bathing the patient

Assess the chest and back for skin breakdown

Assess pin sites frequently for signs of infection

Tape a halo wrench to the vest for emergencies

Answer and Explanation

Correct Answer : C,D,E

Choice A reason:

Soaking the pin sites with alcohol pads is not recommended as it can dry out the skin and increase the risk of infection. Pin site care typically involves using saline or other recommended solutions to clean the area gently.

Choice B reason:

Removing the vest when bathing the patient is not recommended. The vest provides stability and support for the spinal fracture, and removing it can compromise the patient's safety. Alternative methods should be used to maintain hygiene without removing the vest.

Choice C reason:

Assessing the chest and back for skin breakdown is crucial in patients with a halo device to prevent pressure ulcers and other skin issues. Regular assessment helps identify any potential problems early.

Choice D reason:

Assessing pin sites frequently for signs of infection is essential to prevent complications. Infection at the pin sites can lead to serious issues, and frequent monitoring ensures any signs of infection are caught and treated promptly.

Choice E reason:

Taping a halo wrench to the vest is important for emergencies. The wrench is necessary to quickly remove the halo device if needed in an emergency situation, such as if the patient requires resuscitation.

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Correct Answer is ["A","B","C","E"]

Explanation

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.

A. Lower levels of arterial carbon dioxide facilitate brain oxygenation. B. Carbon dioxide is a waste product that must be eliminated from the body. C. Carbon dioxide is a vasodilator that can cause increased intracranial pressure. D. Lower levels of arterial carbon dioxide (PaCO2) are essential for gas exchange.

Correct Answer is C

Explanation

Choice A reason:

Lower levels of arterial carbon dioxide do not directly facilitate brain oxygenation. While maintaining appropriate CO2 levels is important for overall respiratory function, the primary reason for targeting a specific PaCO2 range in traumatic brain injury is related to intracranial pressure control.

Choice B reason:

Although carbon dioxide is indeed a waste product that must be eliminated from the body, this statement does not explain why specific PaCO2 levels are targeted in the context of traumatic brain injury. The primary concern is the impact of CO2 on intracranial pressure.

Choice C reason:

Carbon dioxide is a potent vasodilator, and elevated levels can lead to increased intracranial pressure (ICP). By maintaining PaCO2 within a range of 35-38 mmHg, the healthcare provider aims to prevent hypercapnia and the resulting vasodilation, which can exacerbate intracranial hypertension in patients with traumatic brain injury.

Choice D reason:

Lower levels of arterial carbon dioxide are not specifically essential for gas exchange. The primary concern with PaCO2 management in traumatic brain injury is controlling intracranial pressure, rather than optimizing gas exchange alone.

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The nurse is preparing to care for a patient with a spinal fracture who has a halo device in place. The nurse plans to implement the following orders:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is ["A","B","C","E"]

Explanation

Why does the healthcare provider prescribe a ventilator setting to maintain partial pressure of arterial carbon dioxide (PaCO2) between 35 and 38 mmHg for a patient with traumatic brain injury?

Correct Answer is C

Explanation

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