Chapter 63: Management of Patients with Neurologic Trauma (p. 2056 - 2086)

Which Glasgow Coma Scale score is indicative of a severe head injury? A. 7 B. 9 C. 11 D. 13

A. 7 A score between 3 and 8 is generally accepted as indicating a severe head injury.

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? A. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. B. Contusions are deep brain injuries. C. Contusions are microscopic brain injuries. D. Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

A. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.

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

A. 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.

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

A. 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 with quadriplegia is in spinal shock. What finding should the nurse expect? A. absence of reflexes along with flaccid extremities B. positive Babinski's reflex along with spastic extremities C. hyperreflexia along with spastic extremities D. spasticity of all four extremities

A. 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.

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

A. 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.

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. decerebrate B. normal C. flaccid D. decorticate

A. 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. ecchymosis over the mastoid B. bruising under the eyes C. drainage of cerebrospinal fluid from the nose D. drainage of cerebrospinal fluid from the ears

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

A. 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 patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? A. irrigates the wound to remove debris B. administers an oral analgesic for pain C. administers acetaminophen (Tylenol) for headache D. shaves the haIR around the wound

A. 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.

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? A. provide factual information and emotional support B. allow family members distance and space to deal with the changes to the client C. wait for the family members to approach with questions D. reassure them that progress will be made, but it takes time

A. provide factual information and emotional support During the most acute phase of injury, family members need factual information and support from the health care team. Allowing distance and space can alienate the family, and make them feel like they are not involved with the client. The family may be unsure of approaching the nurse and may not know what questions to ask. The nurse should be available and offer information to start. He or she should not provide false reassurance; they need factual information at this time.

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. take daily weights B. reposition the client frequently C. assess for pupillary response frequently D. assess vital signs frequently

A. 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.

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

B. "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 patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? A. It is the only device that can be applied for stabilization of a spinal fracture. B. It allows for stabilization of the cervical spine along with early ambulation C. It is less bulky and traumatizing for the patient to use. D. The patient can remove it as needed.

B. It allows for stabilization of the cervical spine along with early ambulation Halo devices provide immobilization of the cervical spine while allowing early ambulation.

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

B. 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.

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? A. A bloodstain surrounded by a yellowish stain on the head dressing B. an area of bruising over the mastoid bone C. escape of cerebrospinal fluid from the client's ear D. escape of cerebrospinal fluid from the client's nose

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

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? A. concussion B. contusion C. diffuse axonal injury D. intracranial hemorrhage

B. contusion Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours. 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.

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. naloxone (Narcan) B. famotidine (Pepcid) C. nitroglycerin (Nitro-Bid) D. atracurium (Tracurium)

B. 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.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? A. impaired physical mobility B. ineffective breathing pattern C. disturbed sensory perception (tactile) D. dressing or grooming self-care deficit

B. ineffective breathing pattern Because a cervical injuspinery can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.

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 permanent deficits seen after the rehabilitation process D. it refers to the difficulties suffered by the client and family related to the changes in the client

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.

The nurse provides care for a client who experiences a spinal cord injury (SCI). Which potential long-term complication(s) should the nurse include in the client's updated plan of care? Select all that apply. A. spinal shock B. pressure injury C. respiratory arrest D. respiratory infection E. autonomic dysreflexia

B. pressure injury D. respiratory infection E. autonomic dysreflexia Long-term complications include autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain. Respiratory arrest and spinal shock are immediate, not long-term, complications of SCI.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A. epidural B. subdural C. intracerebral D. cerebral

B. subdural A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first? A. the client with an open head injury B. the client with a basilar fracture C. the client with a concussion D. the client with a coup injury

B. the client with a basilar fracture Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.

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

C. 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 patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A. an epidural hematoma B. an extradural hematoma C. an intracerebral hematoma D. A subdural hematoma

C. 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.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A. tetraplegia B. areflexia C. autonomic dysreflexia D. paraplegia

C. autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? A. hypophysectomy B. application of halo traction C. burr holes D. insertion of Crutchfield tongs

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

Which is the most common cause of spinal cord injury (SCI)? A. falls B. sports related injuries C. motor vehicle crashes D. acts of violence

C. motor vehicle crashes The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is: A. falls B. sports-related injuries C. motor vehicle crashes D. acts of violence

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

A 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. mild TBI B. moderate TBI C. severe TBI D. brain death

C. 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.

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

C. 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.

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

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

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury

D. 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 admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? A. Disturbed sensory perception (visual) related too neurologic trauma B. Feeding self-care deficit related to neurologic trauma C. Impaired verbal communication related to confusion D. Risk for injury related to neurologic deficit

D. Risk for injury related to neurologic deficit Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.

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

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

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

D. 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).

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. ​

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 the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with 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 has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client: A. reports a headache B. reports generalized weakness C. sleeps for short periods of time D. vomits

D. vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of a 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.