Chapter 68: Management of Patients With Neurologic Trauma

(see full question) A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Correct response: Paresthesia

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Correct response: Suction the airway.

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

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?

Monitoring is needed as rapid neurologic deterioration may occur.

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

You selected: A small amount of yellow drainage at the left pin insertion site

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

You selected: Body temperature

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

You selected: Change in level of consciousness (LOC)

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?

You selected: Decerebrate

(see full question) The nurse is conducting a health fair on spinal cord injury (SCI) at a local high school. The nurse relays that which of the following is the most common cause of SCI?

You selected: Motor vehicle crashes

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

You selected: Neurologic examination

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.

You selected: • Bradycardia • Hypertension • Bradypnea

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

• Respiratory irregularities • Slow bounding pulse • Widened pulse pressure

(see full question) Which of the following are risk factors for SCI? Select all that apply.

• Young age • Alcohol use • Drug abuse

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? You selected: 80 mL/hr

Correct Explanation: 20/15 × 60 = 80 mL/hr

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.

Correct response: 0.5

A posttraumatic seizure that is classified as early, occurs within which timeframe?

Correct response: 1 to 7 days of injury

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

You selected: Spasticity

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?

Correct response: An intracerebral hematoma

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?

Correct response: Autonomic dysreflexia

(see full question) After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Correct response: Flat, except for logrolling as needed

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Correct response: Herniation

(see full question) The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

Correct response: Insertion of a nasogastric tube

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Correct response: Loss of consciousness

At which level of cord injury does a patient have full head and neck control?

You selected: C5

(see full question) The nurse has documented a patient diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as which of the following?

You selected: Coma

(see full question) The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

You selected: Conception is not impaired; the birth process is determined with the physician.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

You selected: Ecchymosis over the mastoid

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

You selected: Edema to the head with bruising of the mastoid process

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

You selected: vomits. Correct

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: You selected: to continue I.V. administration of other scheduled medications. Incorrect

Correct response: she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

You selected: The client has cerebral spinal fluid (CSF) leaking from the ear.You selected: The client has cerebral spinal fluid (CSF) leaking from the ear.

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?

subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

(see full question) A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? You selected: Subacute Incorrect

Correct response: Acute

The nurse reviews the physician's emergency department progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign. The nurse knows that the physician observed which clinical manifestation?

Correct response: An area of bruising over the mastoid bone

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? You selected: A subdural hematoma Incorrect

Correct response: An intracerebral hematoma

The most important nursing priority of treatment for a patient with an altered LOC is to: You selected: Position the patient to prevent injury and ensure dignity. Incorrect

Correct response: Maintain a clear airway to ensure adequate ventilation.

The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP?

Correct response: Maintaining cerebral perfusion pressure from 50 to 70 mm Hg

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:

Correct response: Severe TBI.

(see full question) The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction?

You selected: "I can apply powder under the liner to help with sweating."

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

You selected: Absence of reflexes along with flaccid extremities

A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?

You selected: Acute

You are a neuro trauma 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?

You selected: Autonomic dysreflexia

At which of the following spinal cord injury levels does the patient have full head and neck control?

You selected: C5

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:

You selected: Glasgow Coma Scale of 6

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

You selected: Ineffective airway clearance related to brain injury

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

You selected: Irrigates the wound to remove debris

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?

You selected: Look for signs of increased intracranial pressure

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?

You selected: Meticulous cleanliness

Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP?

You selected: Pupils are showing progressive dilation.

The nurse is caring for a patient with a head injury. The patient is experiencing CSF rhinorrhea. Which of the following orders should the nurse question?

You selected: Insertion of a nasogastric (NG) tube

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

You selected: Monitoring the patency of an indwelling urinary catheter

Which Glasgow Coma Scale score is indicative of a severe head injury?

You selected: 7

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?

You selected: Basilar skull fracture

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?

You selected: Raise the head of the bed and place the patient in a sitting position

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

You selected: Risk for injury related to neurologic deficit

Which of the following are characteristics of autonomic dysreflexia?

You selected: Severe hypertension, slow heart rate, pounding headache, sweating

Which of the following are the immediate complications of spinal cord injury?

You selected: Spinal shock

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

You selected: Subdural hematoma

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury?

Correct response: It results from inadequate delivery of nutrients and oxygen to the cells.

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?

Correct response: Meticulous cleanliness

The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury?

Correct response: Spinal shock

A 7-year-old gymnast fell off the balance beam at practice, striking her head. She was taken to surgery to repair an epidural hematoma and arrives postoperatively at the ICU where you practice nursing. In your postoperative assessments, you measure her temperature every 15 minutes. Why is this measurement important?

Correct response: To decrease the potential for brain damage

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

You selected: Subdural

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

You selected: Suction the airway.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

You selected: T6

(see full question) The nurse is caring for a patient with TBI (traumatic brain injury). The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern?

You selected: Temperature increase from 98.0°F to 99.6°F