Chapter 39: Caring for Clients with Head and Spinal Cord Trauma

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? a. T6 b. S2 c. L4 d. T10

a Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

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: a. chronic traumatic encephalopathy. b. a blood clot. c. ALS. d. stroke.

a When concussions occur repetitively, they can result in a form of neurode generation known as chronic traumatic encephalopathy.

What are the immediate complications of spinal cord injury? Select all that apply. a. respiratory arrest b. spinal shock c. tetraplegia d. paraplegia

a, b Spinal shock can be an immediate complication of spinal cord injury.

Which signs are considered cardinal signs of brain death? Select all that apply. a. Absence of brainstem reflexes b. No brain waves c. Apnea d. Coma

a, c, d The three cardinal signs of brain death on clinical examination are coma, the absence of brainstem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brainstem auditory-evoked potential, are often used to confirm brain death.

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? a. Complete the pin site care to decrease risk of infection. b. Notify the neurosurgeon of the occurrence. c. Stabilize the head in a lateral position. d. Reattach the pin to prevent further head trauma.

b If one of the pins became detached, the head is stabilized in neutral position by one person while another notifies the neurosurgeon. Reattaching the pin as a nursing intervention would not be done due to risk of increased injury. Pin site care would not be a priority in this instance. Prevention of neurologic injury is the priority.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? a. Have the client avoid physical exertion b. Emphasize complete bed rest c. Look for signs of increased intracranial pressure d. Look for a halo sign

c The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

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? a. Babinski sign b. Kernig's sign c. Battle's sign d. Brudzinski's sign

c An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. A positive Kernig's and positive Brudzinski's sign indicate meningeal irritation. Babinski's sign (reflex) is indicative of central nervous system disease in the corticospinal tract.

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? a. An epidural hematoma b. An extradural hematoma c. An intracerebral hematoma d. A subdural hematoma

c Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? a. Increased pulse b. Decreased respirations c. Widened pulse pressure d. Decreased body temperature

c Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature. Bradycardia, slowing of the pulse, is an indication of increasing ICP in the head-injured patient. Rapid respiration is an indication of increasing ICP in the head-injured patient. A rapid rise in body temperature is regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.

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? a. At the client's request b. Each morning and evening c. Every 2 hours d. One hour prior to mobility exercises

c The feet are prone to foot drop; therefore, various types of splints are used to prevent foot drop. When used, the splints are removed and reapplied every 2 hours.

A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is: a. a result of venous bleeding into the space below the dura. b. a result of arterial bleeding into the space above the dura. c. bleeding within the brain. d. a result of venous bleeding into the space above the dura.

a A subdural hematoma is a result of venous bleeding into the space below the dura and is further classified as acute, subacute, and chronic according to the rate of neurologic changes. An epidural hematoma results from arterial bleeding into the space above the dura. Bleeding within the brain describes an intracerebral hematoma.

Which are characteristics of autonomic dysreflexia? a. severe hypertension, slow heart rate, pounding headache, sweating b. severe hypotension, tachycardia, nausea, flushed skin c. severe hypertension, tachycardia, blurred vision, dry skin d. severe hypotension, slow heart rate, anxiety, dry skin

a Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

A client is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this client to evaluate the brain structure? a. MRI b. PET scan c. X-ray d. Ultrasound

a CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

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? a. Prepare to transfuse packed red blood cells. b. Prepare for interventions to increase the client's BP. c. Place the client in the Trendelenburg position. d. Prepare an ice bath to lower core body temperature.

b Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.

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: a. Decreased intravascular volume b. Increased intracranial pressure (ICP) c. Ischemic cerebrovascular accident (CVA) d. Brain tissue necrosis

b The pathological effects of an epidural hematoma are primarily a result of the consequent increase in ICP. Blood loss, ischemia, and necrosis are not the primary sequelae of an epidural hematoma.

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? a. acute b. chronic c. subacute d. intracerebral

a Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a. Absence of reflexes along with flaccid extremities b. Positive Babinski's reflex along with spastic extremities c. Hyperreflexia along with spastic extremities d. Spasticity of all four extremities

a During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a. Herniation b. Autoregulation c. Cushing's response d. Monro-Kellie hypothesis

a Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

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? a. Ecchymosis over the mastoid b. Bruising under the eyes c. Drainage of cerebrospinal fluid from the nose d. Drainage of cerebrospinal fluid from the ears

a With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

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? a. Change the client's position frequently. b. Provide a high-protein diet. c. Provide light massage at least daily. d. Teach the client deep breathing and coughing exercises.

a Frequent position changes are among the best preventative measures against pressure ulcers. A high-protein diet can benefit wound healing, but does not necessarily prevent skin breakdown. Light massage and deep breathing do not protect or restore skin integrity.

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. a. Young age b. Frequent travel c. African American race d. Male gender e. Alcohol or drug use

a, d, e The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. Ethnicity and travel are not risk factors.

A client with a spinal cord injury has full head and neck control when the injury is at which level? a. C1 b. C2 to C3 c. C4 d. C5

d At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

At which of the following spinal cord injury levels does the patient have full head and neck control? a. C5 b. C4 c. C3 d. C2

a At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

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? a. Care of the cervical collar b. Technique for performing neck ROM exercises c. Home assessment of ABGs d. Techniques for restoring nerve function

a Prior to discharge, the nurse should assess the client's use and care of the cervical collar. Neck ROM exercises would be contraindicated and ABGs cannot be assessed in the home. Nerve function is not compromised by a discectomy.

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 a. Falls b. Sports-related injuries c. Motor vehicle crashes d. Acts of violence

c The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

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? a. Simple b. Comminuted c. Depressed d. Basilar

d Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).

The earliest sign of serious impairment of brain circulation related to increased ICP is: a. A bounding pulse. b. Bradycardia. c. Hypertension. d. A change in consciousness.

d The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? a. Autonomic dysreflexia b. Thrombophlebitis c. Orthostatic hypotension d. Spinal shock

a Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as a. coma. b. minimally responsive. c. least responsive. d. most responsive.

a The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status? a. Reflex activity b. Level of consciousness c. Cognitive ability d. Sensory involvement

b The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.

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: a. Increasing intracranial pressure (ICP) b. An epidural hematoma c. Leakage of cerebrospinal fluid (CSF) d. Meningitis

c In patients with a skull fracture, a halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. This finding is not specifically indicative of meningitis, increased ICP or an epidural hematoma.

Which condition occurs when blood collects between the dura mater and arachnoid membrane? a. Intracerebral hemorrhage b. Epidural hematoma c. Extradural hematoma d. Subdural hematoma

d A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

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? a. Disturbed sensory perception (visual) b. Dressing or grooming self-care deficit c. Impaired verbal communication d. Risk for injury

d Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

A client was involved in a motor-vehicle collision. At the emergency department, diagnostic tests indicated a brain contusion. The client was admitted to the ICU for observation. What factor determines the magnitude of the signs and symptoms? a. degree of head velocity b. location of head wound c. seatbelt use d. loss of consciousness

a Signs and symptoms vary depending on the severity of the blow and the degree of head velocity.

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? a. Respiratory distress and projectile vomiting b. Bradycardia and hypertension c. Tachycardia and agitation d. Third-spacing and hyperthermia

b Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.

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? a. Epistaxis b. Periorbital edema c. Bruising over the mastoid d. Unilateral facial numbness

c An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture.

A client is brought to the ED by her family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention? a. Insertion of an intracranial monitoring device b. Treatment with antihypertensives c. Making openings in the skull d. Administration of anticoagulant therapy

c An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be prescribed for a client who has a cranial bleed. This could further increase bleeding activity. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this client.

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? a. Repositioning the client every 2 hours b. Initiating range-of-motion exercises (ROM) as soon as the client initiates c. Initiating (ROM) exercises as soon as possible after the injury d. Performing ROM exercises once a day

c Passive ROM exercises should be implemented as soon as possible after injury. It would be inappropriate to wait for the client to first initiate exercises. Toes, metatarsals, ankles, knees, and hips should be put through a full ROM at least four, and ideally five, times daily. Repositioning alone will not prevent contractures.

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? a. "I will change the vest liner periodically." b. "If a pin becomes detached, I'll notify the surgeon." c. "I can apply powder under the liner to help with sweating." d. "I'll check under the liner for blisters and redness."

c Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

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? a. Occipital skull fracture b. Temporal skull fracture c. Frontal skull fracture d. Basilar skull fracture

d A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

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? a. Irrigates the wound to remove debris b. Administers an oral analgesic for pain c. Administers acetaminophen (Tylenol) for headache d. Shaves the hair around the wound

a Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

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? a. The client reports a headache. b. The client reports pain at the site where the ball hits his head. c. The client is visibly fatigued. d. The client's speech is slightly slurred.

d Slurred speech would indicate a need for further assessment and observation due to the possibility of more serious trauma. Localized pain, a headache and fatigue are consistent with a concussion and do not necessarily require further intervention.

A halo sign is indicative of which of the following complication of brain injury? a. Cerebrospinal fluid (CSF) leak b. Seizure c. Cerebral edema d. Ischemia

a A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.

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? a. Administer an IV bolus of normal saline prior to repositioning. b. Maintain bed rest until normal BP regulation returns. c. Monitor the client's BP before and during position changes. d. Allow the client to initiate repositioning.

c To prevent hypotensive episodes, close monitoring of vital signs before and during position changes is essential. Prolonged bed rest carries numerous risks and it is not possible to provide a bolus before each position change. Following the client's lead may or may not help regulate BP.

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? a. Restrain the client as ordered. b. Administer opioids PRN as prescribed. c. Arrange for friends and family members to sit with the client. d. Pad the side rails of the client's bed.

d To protect the client from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless clients should be avoided because these medications can depress respiration, constrict the pupils, and alter the client's responsiveness. Visitors should be limited if the client is agitated.

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? a. Preparation for emergency craniotomy b. Watchful waiting and close monitoring c. Administration of inotropic drugs d. Fluid resuscitation

b Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the client is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer? a. "The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel." b. "The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state." c. "Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing." d. "The sudden, severe headache increases muscle tone and can cause further nerve damage."

a The sudden increase in BP may cause a rupture of one or more cerebral blood vessels or lead to increased ICP. Autonomic dysreflexia does not directly cause nerve damage.

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. a. Making nursing assessments b. Setting priorities for nursing interventions c. Anticipating needs and complications d. Initiating rehabilitation e. Ensuring that the patient regains full brain function

a, b, c, d The nursing interventions for the patient with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? a. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. b. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. c. Reassure the client that a headache is expected and will go away without treatment. d. Notify the physician; a headache is an early sign of worsening neurologic status.

b Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

A client with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring? a. Placing the client on a fluid restriction as ordered b. Applying thigh-high elastic stockings c. Administering an antifibrinolytic agent d. Assisting the client with passive range-of-motion (PROM) exercises

b It is important to promote venous return to the heart and prevent venous stasis in a client with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The client should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation. PROM exercises are not an effective protection against the development of DVT.

The most important nursing priority of treatment for a patient with an altered LOC is to: a. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. b. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. c. Maintain a clear airway to ensure adequate ventilation. d. Position the patient to prevent injury and ensure dignity.

c The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.

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? a. Limit the amount of assistance provided with ADLs. b. Collaborate with the physical therapist and immobilize the client's extremities temporarily. c. Increase the frequency of ROM exercises. d. Educate the client about the importance of frequent position changes.

c To prevent disuse syndrome, ROM exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.

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? a. Hypophysectomy b. Application of Halo traction c. Burr holes d. Insertion of Crutchfield tongs

c An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

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? a. Palpate the surgical site. b. Remove the dressing to assess the surgical site. c. Call the surgeon to report the client's pain. d. Administer a dose of an NSAID.

c If the client experiences a sudden increase in pain, extrusion of the graft may have occurred, requiring reoperation. A sudden increase in pain should be promptly reported to the surgeon. Administration of an NSAID would be an insufficient response and the dressing should not be removed without an order. Palpation could cause further damage.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: a. raccoon's eyes and Battle sign. b. nuchal rigidity and Kernig's sign. c. motor loss in the legs that d. exceeds that in the arms. Pupillary changes.

a A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? a. Baclofen b. Dexamethasone c. Mannitol d. Phenobarbital

a Baclofen is classified as an antispasmodic agent in the treatment of muscle spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in clients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.

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? a. Immediate craniotomy b. An order for a head computed tomography scan c. Intubation and mechanical ventilation d. IV administration of propofol

a The client is experiencing an epidural hematoma. An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure (ICP) emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the client is awake and conversant. During this lucid interval, the expanding hematoma is compensated for by rapid absorption of cerebrospinal fluid and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The client then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

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. A bloodstain surrounded by a yellowish stain on the head dressing b. An area of bruising over the mastoid bone c. Escape of cerebrospinal fluid from the client's ear d. Escape of cerebrospinal fluid from the client's nose

b Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? a. Examine the skin for any area of pressure or irritation. b. Examine the rectum for a fecal mass. c. Empty the bladder immediately. d. Raise the head of the bed and place the patient in a sitting position.

d The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

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 a. reports a headache. b. reports generalized weakness. c. sleeps for short periods of time. d. vomits.

d Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

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? a. Help the family understand that the client could have died. b. Emphasize the importance of accepting the client's new limitations. c. Have the members of the family plan the client's inpatient care. d. Assist the family in setting appropriate short-term goals.

d Helpful interventions to facilitate coping include providing family members with accurate and honest information and encouraging them to continue to set well-defined, short-term goals. Stating that a client's condition could be worse downplays their concerns. Emphasizing the importance of acceptance may not necessarily help the family accept the client's condition. Family members cannot normally plan a client's hospital care, although they may contribute to the care in some ways.

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? a. Ask the client if there is pain on ambulation. b. Ask if the client can walk. c. Have the client lie on the back and lift the leg, keeping it straight. d. Ask if the client has had a bowel movement.

c A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? a. Epidural hemorrhage b. Hypertensive emergency c. Spinal shock d. Hypovolemia

c In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? a. Place the client in a sitting position. b. Lay the client flat. c. Apply antiembolic stockings. d. Notify the physician.

a The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

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? a. Temperature increase from 98.0°F to 99.6°F b. Urinary output increase from 40 to 55 mL/hr c. Heart rate decrease from 100 to 90 bpm d. Pulse oximetry decrease from 99% to 97% room air

a Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention? a. Insertion of an intracranial (IC) monitoring device b. Treatment with antihypertensives c. Emergency craniotomy d. Administration of anticoagulant therapy

c An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed because this could further increase bleeding activity. Insertion of an IC monitoring device may be done during the surgery, but is not the immediate priority for this patient.

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? a. Grade 1 concussion b. Grade 2 concussion c. Grade 3 concussion d. Grade 4 concussion

c There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).

A high school basketball player collides with another player during a game, falls, and hits their head on the court. An MRI reveals small hemorrhages in brain tissue and edema at the injury site. The ED physician explains that the client has a cerebral ________ and further explains that the MRI indicates that the head's direct hit to the floor caused a ________ injury. a. contusion; coup b. contusion; contrecoup c. concussion; coup d. concussion; contrecoup

a A contusion is more serious than a concussion and leads to gross structural injury to the brain. A coup injury occurs when the head is struck directly. Small hemorrhages and edema seen on the MRI indicate a contusion, not a concussion. A coup injury occurs when the head is struck directly, whereas a contrecoup occurs when the force of the injury forces the brain to hit the opposite side of the skull.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? a. Check the client's indwelling urinary catheter for kinks to ensure patency. b. Lower the HOB to improve perfusion. c. Administer PRN analgesia as prescribed. d. Reassure the client that headaches are expected during recovery from spinal cord injuries.

a A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the client's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this client and is not expected.

A nurse is assisting with the preoperative care of a client who requires neurosurgery. Which of the following interventions would the nurse accurately perform? Select all that apply. a. Maintain a record of continuing neurologic assessment findings. b. Administer prescribed phenytoin. c. Ensure increased fluid intake. d. Offer a bedpan every 2 hours. e. Apply antiembolism stockings.

a, b, e To prepare the client for surgery, the nurse maintains a record of continuing neurologic assessment findings. He or she administers prescribed medications, such as the anticonvulsant phenytoin (Dilantin) to reduce the risk of seizures before and after surgery, an osmotic diuretic, and corticosteroids. Preoperative sedation usually is omitted. Before surgery, the nurse restricts fluids to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting. If indicated, the nurse inserts an indwelling urethral catheter and intravenous (IV) line. To prevent thrombophlebitis and deep vein thrombosis, which may develop from prolonged inactivity during neurosurgery, the nurse applies antiembolism stockings.

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? a. "I will change the vest liner periodically." b. "If a pin becomes detached, I'll notify the surgeon." c. "I can apply powder under the liner to help with sweating." d. "I'll check under the liner for blisters and redness."

c Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? a. Place the patient in a sitting position. b. Call the physician. c. Assess the patient for a full bladder. d. Assess the patient for a fecal impaction.

a Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower blood pressure.