Chapter 39: Caring for Clients with Head and Spinal Cord Trauma
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? "I will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."
"I can apply powder under the liner to help with sweating."
A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? Absence of reflexes along with flaccid extremities Positive Babinski reflex along with spastic extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities
Absence of reflexes along with flaccid extremities
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 chronic subacute intracerebral
Acute
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? A bloodstain surrounded by a yellowish stain on the head dressing An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's ear Escape of cerebrospinal fluid from the client's nose
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 epidural hematoma An extradural hematoma An intracerebral hematoma A subdural hematoma
An intracerebral hematoma
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? Placing the patient on a fluid restriction Applying thigh-high elastic stockings Administering an antifibrinolytic agent Assisting the patient with passive range of motion exercises
Applying thigh-high elastic stockings
The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? Help the family understand that the client could have died. Emphasize the importance of accepting the client's new limitations. Have the members of the family plan the client's inpatient care. Assist the family in setting appropriate short-term goals.
Assist the family in setting appropriate short-term goals.
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? Simple Comminuted Depressed Basilar
Basilar
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? Occipital skull fracture Temporal skull fracture Frontal skull fracture Basilar skull fracture
Basilar skull fracture
The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? Babinski sign Kernig's sign Battle's sign Brudzinski's sign
Battle's sign
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? Respiratory distress and projectile vomiting Bradycardia and hypertension Tachycardia and agitation Third-spacing and hyperthermia
Bradycardia and hypertension
The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture? Epistaxis Periorbital edema Bruising over the mastoid Unilateral facial numbness
Bruising over the mastoid
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? Hypophysectomy Application of Halo traction Burr holes Insertion of Crutchfield tongs
Burr holes
A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5
C5
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? C3 C5 T6 L1
C5
The nurse responds to the call light of a client who has had a cervical discectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action? Palpate the surgical site. Remove the dressing to assess the surgical site. Call the surgeon to report the client's pain. Administer a dose of an NSAID.
Call the surgeon to report the client's pain.
A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? Care of the cervical collar Technique for performing neck ROM exercises Home assessment of ABGs Techniques for restoring nerve function
Care of the cervical collar
A halo sign is indicative of which of the following complication of brain injury? Cerebrospinal fluid (CSF) leak Seizure Cerebral edema Ischemia
Cerebrospinal fluid (CSF) leak
The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? Change the client's position frequently. Provide a high-protein diet. Provide light massage at least daily. Teach the client deep breathing and coughing exercises.
Change the client's position frequently.
Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Eating Breathing Ambulating Transferring to a wheelchair Writing
Eating Breathing Transferring to a wheelchair Writing
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears
Ecchymosis over the mastoid
Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? Epidural Subdural Intracerebral Contusion
Epidural
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? Epidural hematoma Acute subdural hematoma Chronic subdural hematoma Grade 1 concussion
Epidural hematoma
Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. The nurse should remove and reapply the splints when? At the client's request Each morning and evening Every 2 hours One hour prior to mobility exercises
Every 2 hours
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? Ask the client if there is pain on ambulation. Ask if the client can walk. Have the client lie on the back and lift the leg, keeping it straight. Ask if the client has had a bowel movement.
Have the client lie on the back and lift the leg, keeping it straight.
The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications? Vertebral fracture Hematoma at the surgical site Scoliosis Renal trauma
Hematoma at the surgical site
The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? Limit the amount of assistance provided with ADLs. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Increase the frequency of ROM exercises. Educate the client about the importance of frequent position changes.
Increase the frequency of ROM exercises.
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? Risk for impaired skin integrity related to immobility and sensory loss Impaired physical mobility related to loss of motor function Ineffective breathing patterns related to weakness of the intercostal muscles Urinary retention related to inability to void spontaneously
Ineffective breathing patterns related to weakness of the intercostal muscles
A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action? Repositioning the client every 2 hours Initiating range-of-motion exercises (ROM) as soon as the client initiates Initiating (ROM) exercises as soon as possible after the injury Performing ROM exercises once a day
Initiating (ROM) exercises as soon as possible after the injury
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 Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Shaves the hair around the wound
Irrigates the wound to remove debris
A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: Increasing intracranial pressure (ICP) An epidural hematoma Leakage of cerebrospinal fluid (CSF) Meningitis
Leakage of cerebrospinal fluid (CSF)
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure Look for a halo sign
Look for signs of increased intracranial pressure
The most important nursing priority of treatment for a patient with an altered LOC is to: Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation. Position the patient to prevent injury and ensure dignity.
Maintain a clear airway to ensure adequate ventilation.
An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient? Obtain a full set of vital signs. Assess the patient's level of consciousness (LOC). Maintain the patency of the patient's airway. Establish IV access.
Maintain the patency of the patient's airway.
A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? Administer an IV bolus of normal saline prior to repositioning. Maintain bed rest until normal BP regulation returns. Monitor the client's BP before and during position changes. Allow the client to initiate repositioning.
Monitor the client's BP before and during position changes.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter
Monitoring the patency of an indwelling urinary catheter
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 Falls Sports-related injuries Motor vehicle crashes Acts of violence
Motor vehicle crashes
Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? Complete the pin site care to decrease risk of infection. Notify the neurosurgeon of the occurrence. Stabilize the head in a lateral position. Reattach the pin to prevent further head trauma.
Notify the neurosurgeon of the occurrence.
The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? Position the client in a high Fowler position when in bed. Support the knees with a pillow when the client is in bed. Perform passive ROM exercises as prescribed. Administer NSAIDs as prescribed.
Perform passive ROM exercises as prescribed.
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? Disturbed sensory perception (visual) Dressing or grooming self-care deficit Impaired verbal communication Risk for injury
Risk for injury
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T6 S2 L4 T10
T6
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 Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air
Temperature increase from 98.0°F to 99.6°F
A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? The client will be unable to use a wheelchair. The client will be unable to swallow food. The client will be continent of urine, but incontinent of bowel. The client will require full assistance for all aspects of elimination.
The client will require full assistance for all aspects of elimination
A 13 year old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. What assessment finding would rule out discharging the client? The client reports a headache. The client reports pain at the site where the ball hits his head. The client is visibly fatigued. The client's speech is slightly slurred.
The client's speech is slightly slurred.
A client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Urinary catheters often lead to urinary tract infections. Urinary function is permanently lost following an SCI. Urinary catheters should not remain in place for more than 7 days. Overuse of urinary catheters can exacerbate nerve damage.
Urinary catheters often lead to urinary tract infections.
A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? Preparation for emergency craniotomy Watchful waiting and close monitoring Administration of inotropic drugs Fluid resuscitation
Watchful waiting and close monitoring
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? Increased pulse Decreased respirations Widened pulse pressure Decreased body temperature
Widened pulse pressure
A client had a long and successful ice hockey career but has been forced to retire due to symptoms of depression, memory loss, and difficulty with gait and balance. The neurologist believes the most likely cause of these symptoms is: chronic traumatic encephalopathy. concussion. contusion. cerebral hematoma.
chronic traumatic encephalopathy.
A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for: chronic traumatic encephalopathy. a blood clot. ALS. stroke.
chronic traumatic encephalopathy.
While snowboarding, a client 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 laceration contusion skull fracture
concussion
A client sustained a complete spinal cord injury at C6 that will require long-term management. Which treatment modalities might be used on this client for rehabilitative measures? Select all that apply. functional electrical stimulation (FES) to restore bladder continence treadmill training tendon transfer surgery traction
functional electrical stimulation (FES) to restore bladder continence tendon transfer surgery traction
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 provide a change of scenery maintain psychological well-being passive exercise
maintain sufficient integument capillary pressure
A client was hit in the head with a ball and knocked unconscious. Diagnostic testing determined that the client suffered a subdural hematoma with moderate symptoms. The client is admitted to the ICU for observation. What would the nurse expect the neurologist would order? Select all that apply. observation for changes in LOC ICP monitoring craniotomy mannitol administration
observation for changes in LOC ICP monitoring
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. nuchal rigidity and Kernig's sign. motor loss in the legs that exceeds that in the arms. pupillary changes.
raccoon's eyes and Battle sign.
Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating severe hypotension, tachycardia, nausea, flushed skin severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, slow heart rate, anxiety, dry skin
severe hypertension, slow heart rate, pounding headache, sweating
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 reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
vomits.
A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? The client received a blood transfusion. The client's analgesia regimen was recently changed. The client was not repositioned during the night shift. The client's urinary catheter became occluded.
The client's urinary catheter became occluded.
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury
Ineffective airway clearance related to brain injury
The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? Prepare to transfuse packed red blood cells. Prepare for interventions to increase the client's BP. Place the client in the Trendelenburg position. Prepare an ice bath to lower core body temperature.
Prepare for interventions to increase the client's BP.
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Ecchymosis over the mastoid Bruising under the eyes Drainage of cerebrospinal fluid from the nose Drainage of cerebrospinal fluid from the ears
Ecchymosis over the mastoid
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: Decreased intravascular volume Increased intracranial pressure (ICP) Ischemic cerebrovascular accident (CVA) Brain tissue necrosis
Increased intracranial pressure (ICP)
