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:

prevents a further increase in intracranial pressure.

promotes comfort and rest

restores neutral position of the joints.

prevents the formation of blood clots

Answer and Explanation

The Correct Answer is A

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.

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Correct Answer is A

Explanation

A. Neurogenic shock is a common complication of spinal cord injuries above T6, including T4, due to disruption of sympathetic pathways causing hypotension, bradycardia, and vasodilation.
B. Malignant hyperthermia is a rare genetic reaction to certain anesthetics, unrelated to spinal cord injury.
C. Neuroleptic malignant syndrome is a reaction to antipsychotic drugs, not related to spinal cord injury.
D. Tardive dyskinesia is a side effect of long-term antipsychotic use, unrelated to spinal cord injury.

A. Assess the client for bladder distention. B. Administer a nitrate antihypertensive. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate.

Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

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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:

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Naxlex Comprehensive Predictor Exams

The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

Correct Answer is A

Explanation

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy?

To prevent the leading cause of death for clients with spinal cord injury, collaboration with which member of the interprofessional health care team is a nursing priority?

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:

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?

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?

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.)

A nurse in the emergency department has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next?