Chapter 45: Nursing Management: Patients With Neurologic Trauma

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? A. "They help prevent the development of contractures." B. "They prepare you to function in the absence of your leg function." C. "They help stabilize total body functioning." D. "They aid in restoring your skeletal integrity."

A. "They help prevent the development of contractures." Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.

A client is diagnosed with a traumatic brain injury. Which action will the nurse take to reduce this client's risk of increasing intracranial pressure (ICP)? Select all that apply. A. Avoid rotation of the neck. B. Prevent compression of the jugular veins. C. Assist to keep a position of hip flexion. D. Elevate the head 30 to 45 degrees. E. Keep head midline.

A. Avoid rotation of the neck. B. Prevent compression of the jugular veins. D. Elevate the head 30 to 45 degrees. E. Keep head midline.

A nurse is assessing a client who has sustained a traumatic brain injury. The client's Glasgow Coma Score (GCS) is 15. Which assessment would the nurse most likely document? Select all that apply. A. Best verbal response: oriented B. Best motor response: localizes pain C. verbal response: confusion D. Eye opening response: spontaneous E. Eye opening response: to voice F. Best motor response: obeys command

A. Best verbal response: oriented D. Eye opening response: spontaneous F. Best motor response: obeys command To achieve a GCS of 15 (normal), the client would score a 4 for spontaneous eye opening response, 5 for oriented as best verbal response, and 6 for obeys commands as best motor response. Confusion would lead to a score of 4; eye opening response to voice would lead to a score of 3; localizes pain would lead to a score of 5. None of these together would lead to a score of 15.

The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? A. HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute B. PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute C. pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L D. 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute

A. HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? A. Provide a dimly lit room B. Apply an external urinary sheath catheter C. Administer opioids to the client D. Turn and reposition the client every 2 hours

B. Apply an external urinary sheath catheter A strategy the nurse can implement to prevent client injury is to use an external sheath catheter for a male client if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the client may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils, and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the client every 2 hours maintains skin integrity.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain? A. Diencephalon B. Midbrain C. Cortex D. Medulla

B. Midbrain Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A. Placing the client in Trendelenburg's position B. Monitoring the patency of an indwelling urinary catheter C. Administering zolpidem tartrate (Ambien) D. Assessing laboratory test results as ordered

B. Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? A. Examine the rectum for a fecal mass. B. Place in a seated position. C. Asses the skin for areas of pressure. D. Palpate the bladder for distention.

B. Place in a seated position. 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 people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.

When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? A. Hypotension and tachycardia B. Rising blood pressure and bradycardia C. Hypotension and bradycardia D. Hypertension and narrowing pulse pressure

B. Rising blood pressure and bradycardia Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? A. nervous system B. Sympathetic nervous system C. Central nervous system D. Autonomic nervous system

B. Sympathetic nervous system The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates "feed and breed" functions. The central and peripheral nervous system is a component of the sympathetic nervous system.

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? A. The client has periorbital edema and ecchymosis. B. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. C. The client's level of consciousness has improved. D. The client prefers to rest in the semi-Fowler's position.

B. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? A. Electric or modified manual wheelchair, needs transfer assistance B. The patient will be able to ambulate independently. C. Cane D. Voice or sip-n-puff controlled electric wheelchair

B. The patient will be able to ambulate independently. Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.

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. Battle's sign 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.

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? A. Flaccid B. Normal C. Decorticate D. Decerebrate

C. Decorticate Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? A. Cerebral perfusion pressure (CPP) is 21 mm Hg. B. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP). C. Increased ICP is 12 mm Hg. D. pupils are dilated and fixed.

C. Increased ICP is 12 mm Hg. A ventriculostomy is used to continuously measure ICP and allows cerebral spinal fluid to drain, especially during a period of increased ICP. The normal ICP is 0 to 15 mm Hg, so ICP measured at 12 mm Hg would demonstrate the effectiveness of the ventriculostomy. Dilated and fixed pupils are not a normal assessment finding and would not indicate an improvement in the neurologic system. Cerebral circulation ceases if the ICP is equal to the MAP. Normal CPP is 70 to 100. A CPP reading less than 50 is consistent with irreversible neurologic damage.

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. Apply antiembolic stockings B. Lay the client flat. C. Place the client in a sitting position. D. Notify the physician.

C. Place the client in a sitting position. To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.

A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? A. Coma C. B. High blood pressure C. Apnea D. Infection

D. Infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection. Coma, high blood pressure, and apnea are late signs of increased ICP, not complications.

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. Subdural hematoma 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 with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5 (50 mg/80 mg) X 0.8 mL = 0.5 mL.

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

1.6 (100 mg/125 mg) x 2 mL = 1.6 mL.

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80 20/15 × 60 = 80 mL/hr

A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of stem cell transplantation therapy. Which statement(s) should the nurse include in the teaching? Select all that apply. A. "Harvested stem cells can be reimplanted into the area surrounding the injury." B. "Stem cells can be harvested from an individual's own bone marrow." C. "Stem cells can cause the damaged spinal nerves to repair themselves." D. "Stem cells can replace the damaged nerve cells when they are transplanted." E. "Cells in the spinal cord may regenerate spontaneously when injured."

A. "Harvested stem cells can be reimplanted into the area surrounding the injury." B. "Stem cells can be harvested from an individual's own bone marrow." D. "Stem cells can replace the damaged nerve cells when they are transplanted." When teaching the client about the benefits of stem cell transplantation therapy, the nurse should explain how stem cells are used to treat a spinal cord injury. In particular, the education should emphasize that stem cells are harvested from the client's own bone marrow and can be reimplanted into the area surrounding the injury, replacing the damaged nerve cells when they are transplanted. The spinal cord loses the ability to regenerate when injured, and stem cells replace the injured spinal nerves rather than causing them to repair themselves, so the nurse would be incorrect to include these statements when discussing the therapy with the client.

Which value indicates a normal intracranial pressure (ICP)? A. 5 mm Hg B. 17 mm Hg C. mm Hg D. 27 mm Hg

A. 5 mm Hg ICP is usually measured in the lateral ventricles. Pressure measuring 0 to 10 mm Hg is considered normal. The other values are incorrect.

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 intracerebral hematoma B. An epidural hematoma C. A subdural hematoma D. An extradural hematoma

A. An intracerebral hematoma 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.

A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? A. Decerebrate positioning implying severe dysfunction and brain pathology B. A brain lesion that causes a spontaneous response that changes with electrical activity in the brain C. Cerebral hemisphere pathology that will cause alterations in flaccidity and contraction of motor responses D. Decorticate positioning indicating damage to the upper midbrain

A. Decerebrate positioning implying severe dysfunction and brain pathology Decorticate posture (extension and external rotation) is indicative of brain pathology. Decerebrate posturing indicates deeper and more severe dysfunction than decorticate posturing.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? A. Fever and change in urine clarity B. Frequency of urination C. Burning sensation on urination D. Lower back pain

A. Fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

evel of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. A. Motor response B. Muscle strength C. Intelligence D. Eye opening E. Verbal response

A. Motor response D. Eye opening E. Verbal response LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? A. Oliguria and serum hyponatremia B. Oliguria and serum hyperosmolarity C. Excessive urine output and decreased urine osmolality D. Excessive urine output and serum hyponatremia

A. Oliguria and serum hyponatremia SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply. A. Young age B. Male gender C. Older adult D. Substance abuse E.. Low-income community

A. Young age B. Male gender D. Substance abuse The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.

What is one of the earliest signs of increased ICP? A. decreased level of consciousness (LOC) B. headache C. coma D. Cushing triad

A. decreased level of consciousness (LOC) Headache is a symptom of increased ICP, but decreasing LOC is one of the earliest signs of increased ICP. Cushing triad occurs late in increased ICP. If untreated, increasing ICP will lead to coma.

A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments? A. Assessing the patient's respiratory rate B. Assessing the patient's blood pressure C. Monitoring the patient's cognition D. Monitoring the patient's pain level

B. Assessing the patient's blood pressure For the first 2 weeks following SCI, blood pressure tends to be unstable and quite low. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Close monitoring of vital signs before and during position changes is essential. The other listed assessments should be addressed but they are less closely related to the specific risks associated with this procedure at this point in the patient's recovery.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? A. Spinal shock B. Rebound hypotension C. Urinary tract infection D. Rebound hypertension

B. Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to A. control shivering. B. dehydrate the brain and reduce cerebral edema. C. control fever. D. reduce cellular metabolic demand.

B. dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid. Antipyretics and a cooling blanket are used to control fever in the client with increased ICP. Chlorpromazine may be prescribed to control shivering in the client with increased ICP. Medications such as barbiturates are given to the client with increased ICP to reduce cellular metabolic demands.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: A. hypothermia can cause death to the client. B. shivering in hypothermia can increase ICP. C. hypothermia is indicative of severe meningitis. D. hypothermia is indicative of malaria.

B. shivering in hypothermia can increase ICP. Care must be taken to avoid the development of hypothermia because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure.

Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical. A. 120 mg/dL B. 80 mg/dL C. 180 mg/dL D. 140 mg/dL

C. 180 mg/dL A serum glucose level of over 150 mg/dL is considered a critical value.

Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what? A. Keep the head of bed (HOB) flat at all times B. Perform endotracheal suctioning every hour C. Administer antipyretics on a p.r.n. basis D. Teach the patient to perform the Valsalva maneuver

C. Administer antipyretics on a p.r.n. basis It is important to manage temperature elevations in a patient with suspected increased ICP. A hyperthermic state causes increased ICP. The HOB should be elevated 30 degrees. Suctioning should be done on a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided because this causes increased ICP.

Which of the following is an early sign of increasing intracranial pressure (ICP)? A. Loss of consciousness B. Decerebrate posturing C. Headache D. Vomiting

C. Headache A headache that is constant or increases in intensity is considered an early sign of increasing intracranial pressure (ICP). Loss of consciousness, projectile vomiting, and decerebrate posturing are all later signs of increasing ICP.

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? A. Oliguria and decreased urine osmolality B. Oliguria and serum hyperosmolarity C. Excessive urine output and serum hypo-osmolarity D. Excessive urine output and decreased urine osmolality

D. Excessive urine output and decreased urine osmolality Diabetes insipidus is the result of decreased secretion of antidiuretic hormone (ADH). The client has excessive urine output, decreased urine osmolality, and serum hyperosmolarity.

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? A. Widening pulse pressure B. Irregular respiration C. Hypertension D. Tachycardia

D. Tachycardia Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.

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? A. Assess vital signs frequently. B. Assess for pupillary response frequently. C. Take daily weights. D. Reposition the client frequently.

Take daily weights. A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

At which of the following spinal cord injury levels does the patient have full head and neck control? A. C4 B. C5 C. C2 D. C3

B. C5 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 assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? A. 3 B. 6 C. 12 D. 9

A. 3 LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68).

Episodes of orthostatic hypotension occur in the first 2 weeks after a spinal cord injury. Compare the two blood pressure measurement for each answer. The blood pressure reading obtained when the patient was sitting, is in the left column for comparison. Which of the following shows the blood pressure measurement indicative of orthostatic hypotension? A. 130/80 120/80 B. 140/110 130/110 C. 130/90 125/85 D. 140/100 120/90

140/100 120/90 Orthostatic hypotension is defined as a drop in systolic blood pressure of at least 20 mm Hg or a drop in diastolic pressure of at least 10 mm Hg, regardless of the patient's symptoms. This is compared to blood pressure readings when the patient is sitting.

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? A. Airway clearance B. Risk of injury C. Deficient fluid volume D. Risk for impaired skin integrity

A. Airway clearance The most important consideration in managing the patient with altered LOC is to establish an adequate airway and ensure ventilation.

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. A. Hypertension B. Tachycardia C. Hypotension D. Bradypnea E. Bradycardia

A. Hypertension D. Bradypnea E. Bradycardia The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

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

A. An area of bruising over the mastoid bone Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.

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? A. Applying thigh-high elastic stockings B. Administering an antifibrinolytic agent C. Placing the patient on a fluid restriction D. Assisting the patient with passive range of motion exercises

A. Applying thigh-high elastic stockings It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient 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.

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. Basilar skull fracture B. Occipital skull fracture C. Frontal skull fracture D. Temporal skull fracture

A. Basilar skull fracture 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).

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord B. To increase cerebral perfusion pressure C. To prevent secondary brain injury D. So that the patient will not have a respiratory arrest

A. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

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. A. Bradycardia B. Bradypnea C. Tachycardia D. Hypotension E. Hypertension

A. Bradycardia B. Bradypnea E. Hypertension The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? A. Contusion B. Diffuse axonal injury C. Intracranial hemorrhage D. Concussion

A. Contusion Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: A. Glasgow Coma Scale of 6 B. Apnea C. Absence of brain stem reflexes D. Coma

A. Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

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)? A. Maintain cerebral perfusion pressure from 50 to 70 mm Hg B. Position the client in the supine position C. Administer enemas, as needed D. Restrain the client, as indicated

A. Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

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? A. Monitoring is needed as rapid neurologic deterioration may occur. B. Symptoms will evolve over a period of 1 week. C. The crash cart with defibrillator is kept nearby. D. Bleeding continues into the intracerebral area.

A. Monitoring is needed as rapid neurologic deterioration may occur. The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? A. Placing a blanket over the client B. Voiding C. Placing the client in a sitting position D. Diarrhea

A. Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

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. Risk for injury B. Dressing or grooming self-care deficit C. Disturbed sensory perception (visual) D. Impaired verbal communication

A. Risk for injury 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 with quadriplegia is in spinal shock. What finding should the nurse expect? A. Spasticity of all four extremities B. Absence of reflexes along with flaccid extremities C. Hyperreflexia along with spastic extremities D. Positive Babinski's reflex along with spastic extremities

B. Absence of reflexes along with flaccid extremities 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.

The nurse is assessing a client with a confirmed spinal cord tumor. The client states, "I've been too embarrassed to tell anyone but, I have been awakened at night because I've wet the bed." It would be a priority for the nurse to further assess the client for which complication? A. Spinal cord compression B. Impaired skin integrity C. Urinary tract infection D. Knowledge deficit

A. Spinal cord compression With spinal tumors, there is the risk of compression from the tumor on structures and organs surrounding the spinal cord. Urinary incontinence indicates decreased spinal cord function due to spinal cord injury related to compression from the tumor. Although the nurse may include further assessment for urinary tract infection, knowledge deficit and impaired skin integrity, these would not be the priority assessment. Spinal chord compression is considered a medical emergency and requires immediate treatment to prevent permanent neurologic damage.

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. Heart rate decrease from 100 to 90 bpm C. Urinary output increase from 40 to 55 mL/hr D. Pulse oximetry decrease from 99% to 97% room air

A. Temperature increase from 98.0°F to 99.6°F 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.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? A. Widened pulse pressure B. Increased respirations C. Increased pulse D. Decreased body temperature

A. Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. A. Young age B. Drug abuse C. European American ethnicity D. Alcohol use E. Female gender

A. Young age B. Drug abuse D. Alcohol use The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: A. diminished responsiveness. B. decreasing blood pressure. C. pupillary changes. D. elevated temperature.

A. diminished responsiveness. Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.

To meet the sensory needs of a client with viral meningitis, the nurse should: A. minimize exposure to bright lights and noise. B. increase environmental stimuli. C. promote an active range of motion. D. avoid physical contact between the client and family members.

A. minimize exposure to bright lights and noise. Photophobia and hypersensitivity to environmental stimuli are the common clinical manifestations of meningeal irritation and infection. Therefore, the nurse should provide a calm environment with less stressful stimuli. Physical activity may worsen symptoms; therefore, physical activity should be reduced. Family members do not need to be avoided. People diagnosed with viral meningitis should be instructed to thoroughly wash hands frequently.

Which are characteristics of autonomic dysreflexia? A. severe hypertension, slow heart rate, pounding headache, sweating B. severe hypotension, tachycardia, nausea, flushed skin C. severe hypotension, slow C. heart rate, anxiety, dry skin D. severe hypertension, tachycardia, blurred vision, dry skin

A. severe hypertension, slow heart rate, pounding headache, sweating Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

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

B. "I can apply powder under the liner to help with sweating." 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 nurse on a neurological unit is participating in the care of a female patient who is receiving treatment for a spinal cord injury (SCI) that she experienced 2 weeks ago. The patient's care plan specifies measures to prevent skin breakdown, and the nurse has planned several changes of position during the shift. How should the nurse best reposition this patient? A. Maintain a consistent position unless impending signs of skin breakdown are evident. B. "Log roll" the patient. C. Reposition the patient beginning with the lower extremities. D. Reposition the patient beginning with the upper extremities

B. "Log roll" the patient. Usually, the patient with an SCI is turned every 2 hours by log rolling. Log rolling ensures proper spinal alignment during turning of the patient. Sequential movement, either beginning with the lower or upper extremities, is likely to compromise spinal alignment.

The earliest sign of serious impairment of brain circulation related to increased ICP is: A. A bounding pulse. B. A change in consciousness. C. Bradycardia. D. Hypertension.

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

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention? A. Give acetaminophen per orders. B. Administer corticosteroids as ordered. C. Assess for weight loss. D. Document signs and symptoms of inflammation.

B. Administer corticosteroids as ordered. Cranial arteritis is caused by inflammation, which can lead to visual impairment or rupture of the vessel. Administering the corticosteroid as ordered can decrease the chance of losing vision or vessel rupture. The client should receive an analgesic (acetaminophen) for the pain, but the corticosteroid should help decrease the pain and prevent complications. The nurse should assess for weight loss, but that can be determined after the medication is administered. Signs and symptoms of inflammation should be documented by the nurse after measures have been taken to decrease complications.

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? A. Assist the patient with frequent ambulation. B. Apply elastic stockings to lower extremities. C. Elevate patient's head or follow the physician's directive for body position. D. Take care not to jar the bed or cause unnecessary activity.

B. Apply elastic stockings to lower extremities. To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.

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. Notify the physician; a headache is an early sign of worsening neurologic status. 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. 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. 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 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? A. Tachycardia and hypertension B. Bradycardia and hypertension C. Tachycardia and hypotension D. Bradycardia and hypotension

B. Bradycardia and hypertension Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It may occur in cord lesions above T6 after spinal shock has resolved.

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? A. Mental confusion and pupillary changes B. Decerebrate posturing and loss of corneal reflex C. Loss of gag reflex and mental confusion D. Complaints of headache and lack of pupillary response

B. Decerebrate posturing and loss of corneal reflex Early indications of increasing ICP include disorientation, restlessness, increased respiratory effort, mental confusion, pupillary changes, weakness on onside of the body or in one extremity, and constant, worsening headache. Later indications of increasing ICP include decreasing level of consciousness until client is comatose, decreased or erratic pulse and respiratory rate, increased blood pressure and temperature, widened pulse pressure, Cheyne-Stokes breathing, projectile vomiting, hemiplegia or decorticate or decerebrate posturing, and loss of brain stem reflexes (pupillary, corneal, gag, and swallowing).

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? A. Flaccid B. Decorticate C. Decerebrate D. Normal

B. Decorticate Decorticate posturing is an abnormal posture associated with severe brain injury, characterized by abnormal flexion of the upper extremities and extension of the lower extremities. Decerebration is an abnormal body posture associated with a severe brain injury, characterized by extreme extension of the upper and lower extremities. Flaccidity occurs when the client has no motor function, is limp, and lacks motor tone.

The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis? A. Tachycardia B. Hypotension C. Increased cardiac biomarkers D. Excessive sweating

B. Hypotension Manifestations of neurogenic shock include decreased blood pressure and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Patients do not perspire on the paralyzed portions of their body due to blockage of sympathetic activity.

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. Shaves the hair around the wound B. Irrigates the wound to remove debris C. Administers acetaminophen (Tylenol) for headache D. Administers an oral analgesic for pain

B. Irrigates the wound to remove debris 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.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? A. It results from inadequate delivery of nutrients and oxygen to the cells. B. It results from initial damage to the brain from the traumatic event. C. It refers to the difficulties suffered by the client and family related to the changes in the client. D. It refers to the permanent deficits seen after the rehabilitation process.

B. It results from initial damage to the brain from the traumatic event. The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A. Half-normal saline (0.45% NSS) B. Lactated Ringer's C. Dextrose 5% in water (D5W) D. One-third normal saline (0.33% NSS)

B. Lactated Ringer's With increasing ICP, isotonic normal saline, lactated Ringer's, or hypertonic (3%) saline solutions are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? A. Bradycardia B. Lethargy and stupor C. A bounding pulse D. Hypertension

B. Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

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

B. Look for signs of increased intracranial pressure 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 most important nursing priority of treatment for a patient with an altered LOC is to: A. Position the patient to prevent injury and ensure dignity. B. Maintain a clear airway to ensure adequate ventilation. C. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. D. Prevent dehydration and renal failure by inserting an IV line for fluids and medications.

B. Maintain a clear airway to ensure adequate ventilation. 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.

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? A. Cushing's B. Monro-Kellie C. Hashimoto's disease D. Dawn phenomenon

B. Monro-Kellie The Monro-Kellie hypothesis states that, because of the limited space for expansion in the skull, an increase in any one of its components causes a change in the volume of the others. Cushing's response is seen when cerebral blood flow decreases significantly. Systolic blood pressure increases, pulse pressure widens, and heart rate slows. The Dawn phenomenon is related to high blood glucose levels in the morning in clients with diabetes. Hashimoto's disease is related to the thyroid gland.

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? A. Capillary refill of 2 seconds B. Shivering C. Cool, dry skin D. Urine output of 100 mL/hr

B. Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A. Ataxia B. Spasticity C. Myoclonus D. Akathisia

B. Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? A. T10 B. T6 C. L4 D. S2

B. T6 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 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. chronic B. acute C. subacute D. intracerebral

B. acute 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 nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? A. physical therapist B. spouse C. home care nurse D. chaplain

B. spouse The client's spouse and family would need to be involved in the everyday care of the client; without their support, it is unlikely that the client would be able to manage at home.

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. Thrombophlebitis B. Spinal shock C. Autonomic dysreflexia D. Orthostatic hypotension

C. Autonomic dysreflexia 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.

A public health nurse is participating in a health promotion workshop and is teaching a group of high school students how to respond if a person suffers an apparent spinal cord injury. The nurse should instruct participants to: A. Transfer the victim to a vehicle, and transfer him or her to the nearest hospital. B. Place the victim side-lying until help arrives. C. Keep the victim's head in a neutral position at all times. D. Rapidly assess the passive range of motion of the victim's neck.

C. Keep the victim's head in a neutral position at all times. At the scene of the injury, the patient should be immobilized on a spinal (back) board, with head and neck in a neutral position, to prevent an incomplete injury from becoming complete. Neutral positioning cannot be maintained if the victim is transferred to a car, and passive ROM could cause irreparable damage. A side-lying position is inconsistent with neutral positioning.

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? A. Watch closely for signs of urinary tract infection. B. Keep accurate intake and output. C. Maintain a diet for the client that is high in protein, vitamins, and calories. D. range of motion exercises for the client because of spasms.

C. Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. What medication does the nurse know will be given to prevent further spinal cord damage? A. Furosemide (Lasix) B. Cyclobenzaprine (Flexeril) C. Methylprednisolone (Solu-Medrol) D. Hydralazine hydrochloride (Apresoline)

C. Methylprednisolone (Solu-Medrol) The administration of high-dose corticosteroids, specifically methylprednisolone, has been found to improve motor and sensory outcomes at 6 weeks, 6 months, and 1 year if given within 8 hours of injury. Lasix, Flexeril, and Apresoline are used in the management of spinal cord injury, but do not have an effect on preventing further spinal cord damage, specifically.

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. Raise the head of the bed and place the patient in a sitting position. D. Empty the bladder immediately.

C. Raise the head of the bed and place the patient in a sitting position. 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.

Consider the following laboratory values. Identify a critical result for a patient with a TBI. A. Serum osmolality of 300 mOsm/L B. Hematocrit of 44% C. Serum magnesium of 1.4 mg/dL D. Urine specific gravity of 1.01

C. Serum magnesium of 1.4 mg/dL A serum magnesium values of less than 1.6 mg/dL is considered critical. Hypomagnesemia may lower the seizure threshold and cause secondary brain injury. The other choices are normal values. Refer to Table 45-2 in the text.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A. Ataxia B. Akathisia C. Spasticity D. Myoclonus

C. Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor? A. Lumbar sacral strain B. Hematoma formation C. Spinal metastasis D. The development of a skin ulcer from the radiation

C. Spinal metastasis Pain is the hallmark of spinal metastasis. Patients with sensory root involvement may suffer excruciating pain, which requires effective pain management.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? A. Slight headache B. Runny nose C. Sweating D. Rapid heart rate

C. Sweating Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

A 14-year-old boy was brought to the emergency department (ED) by his father after suffering an apparent concussion during a game. Assessment in the ED confirmed the father's suspicion, and the boy is being discharged home in his father's care. What health education should the nurse provide to the boy's father? A. The boy should not be given ASA, acetaminophen, or ibuprofen for the next 48 hours. B. The boy should sleep with his head elevated for the next 2 nights. C. The father should awaken his son every 2 hours during the night. D. Short-term difficulty in speaking should be expected and will resolve over the next few days.

C. The father should awaken his son every 2 hours during the night. Once the patient with a concussion is discharged home, he or she should be closely observed for the next 24 hours, and awakened every 2 hours. Over-the-counter analgesics are not contraindicated, and it is unnecessary for the patient to sleep with the head of bed elevated. Speech difficulties are a pathological symptom that would warrant further assessment and treatment.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? A. Turning frame B. Cervical collar C. Traction with weights and pulleys D. Cast

C. Traction with weights and pulleys Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? A. Suctioning the client once each shift B. Encouraging oral fluid intake C. Elevating the head of the bed 90 degrees D. Administering a stool softener as ordered

D. Administering a stool softener as ordered To prevent the client from straining at stool, which may cause a Valsalva maneuver that increases ICP, the nurse should institute a regular bowel program that includes use of a stool softener. For a client at risk for increased ICP, the nurse should prevent, not encourage, oral fluid intake and should elevate the head of the bed only 30 degrees. Suctioning, indicated for a client with lung congestion, isn't necessary for this client.

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? A. Contusion B. Concussion C. shock D. Autonomic dysreflexia

D. Autonomic dysreflexia Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A. Extreme thirst B. Intake and output C. Nutritional status D. Body temperature

D. Body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

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. C5 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.

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? A. Normal B. Decorticate C. Flaccid D. Decerebrate

D. Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

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. Drainage of cerebrospinal fluid from the nose B. Bruising under the eyes C. Drainage of cerebrospinal fluid from the ears D. Ecchymosis over the mastoid

D. Ecchymosis over the mastoid 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 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. Drainage of cerebrospinal fluid from the nose B. Drainage of cerebrospinal fluid from the ears C. Bruising under the eyes D. Ecchymosis over the mastoid

D. Ecchymosis over the mastoid 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.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? A. Diffuse axonal B. Intracerebral C. Subdural D. Epidural

D. Epidural An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.

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 4 concussion B. Grade 2 concussion C. Grade 1 concussion D. Grade 3 concussion

D. Grade 3 concussion 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 client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A. Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction B. Ineffective cerebral tissue perfusion related to increased intracranial pressure C. Disturbed thought processes related to brain injury D. Ineffective airway clearance related to brain injury

D. Ineffective airway clearance related to brain injury Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? A. Serum sodium concentration testing B. Out of bed to the chair three times a day C. Urine testing for acetone D. Insertion of a nasogastric (NG) tube

D. Insertion of a nasogastric (NG) tube Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure? A. Blood pressure 100/60 mm Hg B. Nausea C. Periorbital edema D. Lethargy

D. Lethargy Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP). Without a baseline for the blood pressure, it is difficult to determine whether this is a significant change for this client. Vomiting (usually without forewarning of nausea) when associated with a head injury suggests increasing ICP. Periorbital edema is more suggestive of fluid overload than ICP.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? A. Allowing the client to choose the position of comfort B. Continuous use of an indwelling catheter C. Avoidance of all lotions and lubricants D. Meticulous cleanliness

D. Meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

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: A. Moderate TBI. B. Mild TBI. C. death. D. Severe TBI.

D. Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

When the nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet, the nurse records the client's posture as A. normal. B. decorticate. C. flaccid. D. decerebrate.

D. decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The client's head and neck arch backward, and the muscles are rigid. In decorticate posturing, which results from damage to the nerve pathway between the brain and spinal cord and is also very serious, the client has flexion and internal rotation of the arms and wrists, as well as extension, internal rotation, and plantar flexion of the feet.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: A. atracurium (Tracrium). B. nitroglycerin (Nitro-Bid). C. naloxone (Narcan). D. famotidine (Pepcid).

D. famotidine (Pepcid). Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

The Monro-Kellie hypothesis explains A. why the client is awake but lacks consciousness, without cognitive or affective mental function. B. the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. C. nonresponse of the brain to the environment. D. the dynamic equilibrium of cranial contents.

D. the dynamic equilibrium of cranial contents. The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. The Cushing response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the client is wakeful but devoid of conscious content, without cognitive or affective mental function.

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. a headache. B. reports generalized weakness. C. sleeps for short periods of time. D. vomits.

D. vomits. 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.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? A. Maintaining adequate hydration B. Administering prescribed antipyretics C. Restricting fluid intake and hydration D. Hyperoxygenation before and after tracheal suctioning

Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH. Antipyretics are administered to clients who develop hyperthermia. In addition, it is important to maintain adequate hydration in such clients. A client with neurological infection should be given tracheal suctioning and hyperoxygenation only when respiratory distress develops.