Chapter 63 Management of Patients with Neurologic Trauma
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinski reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities
A) Absence of reflexes along with flaccid extremities
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding? A) Absence of reflexes along with flaccid extremities B) Positive Babinskis reflex along with spastic extremities C) Hyperreflexia along with spastic extremities D) Spasticity of all four extremities
A) Absence of reflexes along with flaccid extremities
A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply. A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT D) Salt-wasting syndrome E) Increased ICP
A) Orthostatic hypotension B) Autonomic dysreflexia C) DVT
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses 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 can raise the ICP or rupture a cerebral blood vessel.
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention? A) Urinary retention can have serious consequences in patients with SCIs. B) Urinary function is permanently lost following an SCI. C) Urinary catheters should not remain in place for more than 7 days. D) Overuse of urinary catheters can exacerbate nerve damage.
A) Urinary retention can have serious consequences in patients with SCIs.
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 (Lioresal) B. Dexamethasone (Decadron) C. Mannitol (Osmitrol) D. Phenobarbital (Luminal)
A. Baclofen (Lioresal)
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. Change the client's position frequently.
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. Check the client's indwelling urinary catheter for kinks to ensure patency.
The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A. Ensure that the player is not moved. B. Obtain the player's vital signs, if possible. C. Perform a rapid assessment of the player's range of motion. D. Assess the player's reflexes.
A. Ensure that the player is not moved.
An 82-year-old client is admitted for observation after a fall. Due to the client's age, the nurse knows that the client is at increased risk for what complication of his injury? A. Hematoma B. Skull fracture C. Embolus D. Stroke
A. Hematoma
The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea
A. Hyperthermia
A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure? A. Magnetic resonance imaging (MRI) B. Positron emission tomography (PET) scan C. X-ray of the head D. Ultrasound of the head
A. Magnetic resonance imaging (MRI)
A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP
A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT
A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A. Urinary catheter use often leads to urinary tract infections (UTIs). B. Urinary function is permanently lost following an SCI. C. Urinary catheters should not remain in place for more than 7 days. D. Overuse of urinary catheters can exacerbate nerve damage.
A. Urinary catheter use often leads to urinary tract infections (UTIs).
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. Young age D. Male gender E. Alcohol or drug use
A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart? A) When the patients condition begins to deteriorate B) As soon as the initial assessment is made C) At the beginning of each shift D) When there is a clinically significant change in the patients condition
As soon as the initial assessment is made
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occuring? A) Placing the patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolytic agent D) Assisting the patient with passive range of motion (PROM) exercises
B) Applying thigh-high elastic stockings
A patient 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 patient on a fluid restriction as ordered B) Applying thigh-high elastic stockings C) Administering an antifibrinolyic agent D) Assisting the patient with passive range of motion (PROM) exercises
B) Applying thigh-high elastic stockings
A nurse is reviewing the trend of a patients score on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status? A) Reflex activity B) Level of consciousness C) Cognitive ability D) Sensory involvement
B) Level of consciousness
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents
B) To avoid impeding venous outflow
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? A) To decrease cerebral arterial pressure B) To avoid impeding venous outflow C) To prevent flexion contractures D) To prevent aspiration of stomach contents
B) To avoid impeding venous outflow
A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition
B. An assessment of the client's current level of consciousness
The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of deep tendon reflexes
B. Apnea C. Coma D. Absence of brain stem reflexes
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. Bradycardia and hypertension
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. Notify the neurosurgeon of the occurrence.
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. Prepare for interventions to increase the client's BP.
A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11/2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation
B. Risk for injury
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. Watchful waiting and close monitoring
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. 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) Emergency craniotomy D) Administration of anticoagulant therapy
C) Emergency craniotomy
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient? A) Risk for impaired skin integrity related to immobility and sensory loss B) Impaired physical mobility related to loss of motor function C) Ineffective breathing patterns related to weakness of the intercostal muscles D) Urinary retention related to inability to void spontaneously
C) Ineffective breathing patterns related to weakness of the intercostal muscles
A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action? A) Repositioning the patient every 2 hours B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates C) Initiating (ROM) exercises as soon as possible after the injury D) Performing ROM exercises once a day
C) Initiating (ROM) exercises as soon as possible after the injury
The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A) Position the patient in a high Fowlers position when in bed. B) Support the knees with a pillow when the patient is in bed. C) Perform passive ROM exercises as ordered. D) Administer NSAIDs as ordered.
C) Perform passive ROM exercises as ordered.
Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A. Keep the head of the bed (HOB) flat at all times. B. Teach the client to perform the Valsalva maneuver. C. Administer benzodiazepines on a PRN basis. D. Perform endotracheal suctioning every hour.
C. Administer benzodiazepines on a PRN basis.
The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding(s) are suggestive of a basilar skull fracture? A. Epistaxis B. Swelling of the tongue and lips C. Bruising over the mastoid D. Unilateral facial numbness E. Severe back pain
C. Bruising over the mastoid
The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A. Administer a benzodiazepine at bedtime each night. B. Do not disturb the client between 2200 and 0600. C. Cluster overnight nursing activities to minimize disturbances. D. Ensure that the client does not sleep during the day.
C. Cluster overnight nursing activities to minimize disturbances.
Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? A. At the client's request B. Each morning and evening C. Every 2 hours D. One hour prior to mobility exercises
C. Every 2 hours
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. Increase the frequency of ROM exercises.
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously
C. Ineffective breathing patterns related to weakness of the intercostal muscles
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. Monitor the client's BP before and during position changes.
The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed. D. Administer NSAIDs as prescribed.
C. Perform passive ROM exercises as prescribed.
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. Spinal shock
A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has? A) Diffuse axonal injury B) Grade 1 concussion with frontal lobe involvement C) Contusion D) Grade 3 concussion with temporal lobe involvement
D) Grade 3 concussion with temporal lobe involvement
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 inclient care. D. Assist the family in setting appropriate short-term goals.
D. Assist the family in setting appropriate short-term goals.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting) B. Suicide attempts C. Workplace injuries D. Motor vehicle accidents
D. Motor vehicle accidents
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. Pad the side rails of the client's bed.
The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A. Promoting adequate circulation B. Treating the child's increased ICP C. Assessing secondary brain injury D. Preserving brain homeostasis
D. Preserving brain homeostasis
A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.
D. The client's urinary catheter became occluded.
A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? A) Insertion of an intracranial monitoring device B) Treatment with antihypertensives C) Emergency craniotomy D) Administration of anticoagulant therapy
Emergency craniotomy
