exam 2 460

A client develops a seizure disorder as a result of a traumatic fall. When the client returns to the clinic for a routine visit, the client states, "I have not had a seizure in 2 years. When can I stop taking my antiseizure medications?" What is the nurse's best response?

"A gradual reduction in seizure medication may be considered."

The spouse of a client with an intracranial hemorrhage asks the nurse, "Why aren't they administering an anticoagulant?" How will the nurse respond?

"It is not advisable because bleeding will increase."

Following a traumatic spinal cord severance, a client experiences severe leg spasms and asks the nurse what is causing them. How should the nurse respond?

"Spinal shock has subsided, and your reflexes are hyperactive."

The nurse is providing care to a trauma client. What is the correct order of steps the nurse will implement when providing care to this client?

1. clear the airway 2. protect the cervical spine 3. provide supplemental oxygen. 4. perform chest compressions.

Which parameter does the nurse assess first while assessing a client with severe trauma?

Airway

The nurse is caring for a client who was just admitted to the hospital with the diagnosis of head trauma. Which clinical indicators should the nurse consider as evidence of increasing intracranial pressure?

Anorexia, nausea, and vomiting, irritability and seizures, an altered level of consciousness. The blood pressure will be increased, a decreased respiratory rate, Cheyne-Stokes respirations.

A client is admitted to the unit with a crushed chest, abdominal trauma, a probable head injury, and multiple fractures. The nurse should provide what initial emergency care?

Assess vital signs, control accessible bleeding, and determine the presence of critical injuries

A nurse is caring for a client with a spinal cord injury during the immediate postinjury period. Which is the priority focus of nursing care during this immediate phase?

Avoiding flexion or hyperextension of the spine

The laboratory reports of a client who underwent a hypophysectomy show an intracranial pressure (ICP) of 20 mmHg. Which action made by the client is responsible for this condition?

Bending over at the waist

The nurse is caring for a client with a spinal cord injury who has paraplegia. The nurse can expect which major problem early in the recovery period?

Bladder control

A client was admitted to the hospital with blunt trauma as a result of a collision with the steering wheel during a motor vehicle accident. The client was treated for a lacerated liver and abdominal hemorrhage. Which clinical findings should the nurse be alert for when assessing the client for peritonitis during the recovery period? Select all that apply.

Boardlike abdomen Abdominal tenderness Decreased bowel sounds

A nurse on the disaster management team is caring for survivors of an earthquake. The nurse understands that some survivors may have chest trauma and may need a needle decompression to relieve the air or fluid trapped in the chest. Following the initial assessment, which client would the nurse treat first?

Client C with cyanosis, air hunger, violent agitation, tracheal deviation away from affected side = tension pneumothorax

A client is admitted to the hospital with a tentative diagnosis of a brain tumor. Which diagnostic test result will the nurse check for confirmation of this diagnosis?

Computed tomography

A client is admitted with head trauma after a fall. The client is being prepared for a supratentorial craniotomy with burr holes, and an intravenous infusion of mannitol is instituted. The nurse concludes that this medication primarily is given to do what?

Decrease fluid in the brain

A client is admitted to the hospital after sustaining a head injury. Which is the most reliable sign of increased intracranial pressure the nurse can monitor for?

Decrease in the level of consciousness

The nurse is caring for a client with a spinal cord injury. The client exhibits signs of autonomic hyperreflexia. What does the nurse recall is the most common cause of this response?

Distended large intestine

Which intervention should the nurse implement to help prevent atelectasis in a client with fractured ribs as a result of chest trauma?

Encourage coughing and deep breathing.

The client was admitted to the emergency department due to blunt abdominal trauma. Which action should be the nurse initiate first?

Ensuring a patent airway

The nurse is caring for a client with a spinal cord injury. Which assessment findings alert the nurse that the client is developing autonomic hyperreflexia (autonomic dysreflexia)?

Hypertension and bradycardia

The emergency department (ED) nurse is providing care to a burn trauma client. Which is the priority for the nurse to monitor for after removing the client's clothing?

Hypothermia

The nurse is caring for a client with a spinal cord injury. Which priority intervention should be performed by the nurse immediately? Monitoring urinary output Assessing for other injuries Infusing lactated Ringer solution Immobilizing and stabilizing cervical spine

Immobilizing and stabilizing cervical spine

A nurse in the emergency department is caring for a 9-year-old child with a suspected spinal cord injury sustained while falling off a bicycle. What is the initial nursing action?

Immobilizing the child's spine to limit additional injury

basilar skull fracture

Leakage of cerebrospinal fluid (CSF) from the nose or ear Raccoon eyes (periorbital ecchymosis) and Battle's sign (mastoid ecchymosis).

The nurse finds that a client with a spinal cord injury has developed sudden autonomic dysreflexia. What is the priority nursing action in this situation?

Place in a sitting position

Which is the priority nursing action when providing care to a trauma client whose primary survey indicates a Glasgow Coma Scale of 7?

Preparing for intubation

Dexamethasone has been prescribed for a client after a craniotomy for a brain tumor. When evaluating the effectiveness of the medication, the nurse expects what physiologic response?

Reduced cerebral edema

A client with a spinal cord injury tends to assume the low Fowler position excessively. In which area of the body will the nurse most likely discover a pressure ulcer?

Sacrum

Cushing's triad

Signs of increased intracranial pressure: 1. hypertension 2. bradycardia 3. irregular respirations

A nurse is caring for a client with a spinal cord injury. What is the specific reason fluid intake should be increased for this client?

To prevent a urinary tract infection

The primary reason the nurse encourages a client with a spinal cord injury to increase oral fluid intake is to prevent which problem?

Urinary tract infections

Which is the priority nursing action when providing care to a trauma client?

When providing care during the primary survey of a trauma client, the priority action is assessing respiratory effort. The nurse prioritizes care by assessing the ABC's - airway, breathing, and circulation.

A client with a head injury is admitted to the hospital. Which assessment finding alerts the nurse to increasing intracranial pressure? Hypervigilance Constricted pupils Increased heart rate Widening pulse pressure

Widening pulse pressure

A client admitted in the emergency department has airway obstruction, chest wall trauma, external hemorrhage, and hypoglycemia. Which condition of the client will be given the highest priority?

airway obstruction

A client with recent history of head trauma is at risk of orthostatic hypotension. Which assessment findings would help to diagnose the condition? Select all that apply.

fainting, light-headedness, and weakness

After subarachnoid hemorrhage (SAH) due to bleeding from a cerebral aneurysm, patients are at high risk for complications. Besides rebleeding, complications include:

hydrocephalus (increase in fluid in ventricles) cerebral vasospasm seizures

neurogenic shock

hypotension, bradycardia, warm, dry skin

After a craniotomy to remove a brain tumor, the client develops the syndrome of inappropriate secretion of antidiuretic hormone (ADH). For which clinical indicators should the nurse monitor the client? Select all that apply.

increased weight Decreased serum sodium Decreased level of consciousnes tachycardia

A client has a functional transection of the spinal cord at C7-8, resulting in spinal shock. Which clinical indicators does the nurse expect to identify when assessing the client immediately after the injury? Select all that apply.

Flaccid paralysis Lack of reflexes below the injury

A nurse is caring for a 7-year-old child in the pediatric intensive care unit who has increased intracranial pressure as a result of head trauma. The healthcare provider prescribes intravenous mannitol. The nurse monitors the child's intracranial pressure and urine output because mannitol belongs to which classification of diuretics?

osmotic

A client is at risk for increased intracranial pressure (ICP). Which assessment finding reflects an increase in ICP? Unequal pupil size Decreasing systolic blood pressure Tachycardia Decreasing body temperature

unequal pupil size

A client is hospitalized with head trauma. Which imaging test should the nurse anticipate being prescribed by the primary healthcare provider to rule out a cervical spine fracture?

x-ray

A 7-year-old child loses consciousness a few days after a traumatic head injury that resulted in a subdural hematoma. While assessing extraocular movements, the nurse notes that the child is displaying the oculocephalic reflex. What does the nurse conclude about the presence of the oculocephalic reflex in an unconscious child?

expected

GCS

eye opening response, best verbal response, and best motor response.

A client has sustained a spinal cord injury at the T2 level. The nurse assesses for signs of autonomic hyperreflexia (autonomic dysreflexia). What is the rationale for the nurse's assessment?

The injury is above the sixth thoracic vertebra

The nurse is providing care to a trauma client. Which are priority nursing actions when providing care to this client? Select all that apply.

The priority nursing actions when providing care for a trauma client include starting a large-bore IV, immobilizing any obvious deformities, and removing clothing to allow for an adequate examination.

Why is the Glasgow Coma Scale used by the nurse while performing an assessment in a traumatized client?

To assess level of consciousness

During the immediate posttrauma period after injury to the frontal lobe of the brain, the nurse places a client in what position?

Low-Fowler

A client is admitted with posttraumatic brain injury and multiple fractures. The client's eyes remain closed, and there is no evidence of verbalization or movement when the nurse changes the client's position. What score on the Glasgow Coma Scale (GCS) should the nurse document? Record your answer using a whole number. _______ Total GCS score

3

A client is admitted to the emergency department with the diagnosis of a possible spinal cord injury. The nurse should monitor the client for what clinical manifestations of spinal shock? Select all that apply.

Bradycardia Hypotension Bladder dysfunction

The nurse is monitoring a client with a severe head injury for signs and symptoms of increasing intracranial pressure. Which finding is mostindicative of increasing intracranial pressure? Polyuria Tachypnea Increased restlessness Intermittent tachycardia

Increased restlessness

A client is admitted to the hospital with a head injury sustained while playing soccer. For which early sign of increased intracranial pressure should the nurse monitor this client?

Lethargy is an early sign of a changing level of consciousness; changing level of consciousness is one of the first signs of increased intracranial pressure.

A client had a craniotomy for excision of a brain tumor. After surgery, the nurse monitors the client for increased intracranial pressure. Which clinical finding supports an increase in intracranial pressure?

Lowered level of consciousness

What action should the nurse take when caring for a client who has a possible skull fracture as a result of trauma?

Monitor the client for signs of brain injury.

A client has increased intracranial pressure resulting from a traumatic brain injury. Assessment findings indicate that the client is unconscious with vital signs of pulse 60 beats/min, respirations 16 breaths/min, and blood pressure 142/64 mm Hg. The nurse reviews the treatment plan and questions which prescription? Mannitol Dexamethasone Chlorpromazine Morphine

Morphine bc it depresses respirations

A client who sustained trauma to the chest as a result of an injury has chest tubes inserted and is attached to a closed chest drainage system. When caring for this client, what should the nurse do?

Palpate the area around the tubes for crepitus

Two weeks after sustaining a spinal cord injury, a client begins vomiting thick coffee-ground material and appears restless and apprehensive. What is the most important initial nursing action?

Prepare for insertion of a nasogastric tube

The nurse is caring for a client with trauma in the emergency unit. Which action should the nurse perform as the highest priority? Applying dry dressing Evaluating chest expansion Providing adequate oxygen supply. Applying direct pressure on a bleeding site

Providing adequate oxygen supply.

A healthcare provider prescribes dexamethasone for a client with head trauma. A family member asks why this medication is being given. The nurse explains that it reduces swelling in the brain by what process?

Reduces the inflammatory response of tissues

A nurse is precepting an orientee (newly hired nurse). The nurse observes the orientee caring for an unconscious client with increasing intracranial pressure. The nurse should question which intervention that the orientee performs?

Suctioning the oropharynx routinely