Honan, Chapter 45: Nursing Management: Patients With Neurologic Trauma

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

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?

Airway clearance

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?

Applying thigh-high elastic stockings

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

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

Body temperature

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

Body temperature

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

C5

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?

Decerebrate

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?

Ecchymosis over the mastoid

A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention?

Emergency craniotomy

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

Restricting fluid intake and hydration

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

The Monro-Kellie hypothesis explains

The dynamic equilibrium of cranial contents

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?

The father should awaken his son every 2 hours during the night.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

increase the frequency of the catheterizations.

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client?

5 to 15 mm Hg

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered.

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?

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?

An intracerebral hematoma

A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC?

By assessing according to the Glasgow Coma Scale (GCS)

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Which posturing is the patient exhibiting?

Decerebrate

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

Decorticate

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?

Excessive urine output and decreased urine osmolality

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?

Fever and change in urine clarity

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

Ineffective airway clearance related to brain injury

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?

Insertion of a nasogastric tube

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?

Irrigates the wound to remove debris

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?

It results from initial damage to the brain from the traumatic event.

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

Maintain a clear airway to ensure adequate ventilation.

Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?

Mannitol

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?

Monro-Kellie

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

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

Absence of reflexes along with flaccid extremities

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?

Battle's sign

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

Herniation

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Hypertension Bradycardia Bradypnea

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

Motor vehicle crashes

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

Risk for injury related to neurologic deficit

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:

Severe TBI.

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?

Spinal cord compression

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?

Spinal metastasis

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?

Sweating

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

Tachycardia

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?

Traction with weights and pulleys

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply.

Weakness on one side of the body Slurred speech Vomiting

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma

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

decerebrate

The initial sign of increasing intracranial pressure (ICP) includes

decreased level of consciousness.

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation

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?

Basilar

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?

Basilar skull fracture

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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:

Glasgow Coma Scale of 6

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would indicate that the patient is experiencing increased brain compression causing brainstem damage?

Hyperthermia

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?

Temperature increase from 98.0°F to 99.6°F

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?

acute

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?

spouse