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The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

Use a draw sheet to move the patient

Have the patient grasp the side rail and assist with turning

Cross the lower extremities, turn the hips then turn the shoulders

With one person holding the head, 2 others log roll the client as a unit

Answer and Explanation

The Correct Answer is D

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

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Correct Answer is B

Explanation

A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.

B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.

C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.

D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.

A. Encourage the patient to cough to expectorate secretions B. Elevate the head of the bed to 30-45 degrees C. Stimulate the patient with active range of motion exercises D. Perform serial neurologic assessments while hospitalized E. Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Correct Answer is ["B","D","E"]

Explanation

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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The nurse is preparing to turn the patient who sustained a spinal cord injury. How should the nurse proceed?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

Correct Answer is B

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

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