Ch 68 Neurologic Trauma PrepU

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body temperature

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

Decerebrate

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

Ecchymosis over the mastoid

The nurse is caring for a client who is scheduled for surgery to relieve pressure on a compressed nerve. The compression does not involve the spinal cord. What kind of spinal nerve root compression does the nurse know this is?

Extramedullary

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.

Hypertension Diaphoresis Nasal congestion

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate craniotomy

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Paresthesia

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

Which of the following is not a manifestation of Cushing's Triad?

Tachycardia

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

acute

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

concussion

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

Alteration in level of consciousness (LOC)

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

An intracerebral hematoma

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.

Bradycardia Hypertension Bradypnea

A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and hypertension

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC)

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

Contusion

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories.

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is

Motor vehicle crashes

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear.

A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?

maintain sufficient integument capillary pressure

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal shock

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

Subdural

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

Take daily weights.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?

Assess for a halo sign

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?

Monitoring is needed as rapid neurologic deterioration may occur.

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI.