NUR250 SCI Ch. 68
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?
"I can apply powder under the liner to help with sweating."
The nurse is caring for a patient who is being assessed for brain death. Which of the following are cardinal signs of brain death? Select all that apply.
Absence of brain stem reflexes Apnea Coma
Which of the following are risk factors for SCI? Select all that apply.
Alcohol use Young age Drug abuse
Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?
Apply elastic stockings to lower extremities.
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.
Bradycardia Bradypnea Hypertension
At which level of cord injury does a patient have full head and neck control?
C5
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Change in level of consciousness (LOC)
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
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Subdural
Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?
Subdural hematoma
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?
Temperature increase from 98.0°F to 99.6°F
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 with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.
1.6
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
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?
Acute
The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following 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 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?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.
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?
Autonomic dysreflexia
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?
Autonomic dysreflexia
While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?
Concussion
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 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?
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?
Edema to the head with bruising of the mastoid process
Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?
Epidural
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
Epidural
A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate?
Establishing an intermittent catheterization routine every 4 hours
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
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?
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?
Herniation
A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure?
Hydralazine hydrochloride (Apresoline) IV administered slowly
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.
Hypertension Bradycardia Bradypnea
The nurse is assigned to care for patients with SCI on a rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply.
Hypertension Diaphoresis Nasal congestion
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?
Insertion of a nasogastric (NG) tube
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
A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?
Look for signs of increased intracranial pressure
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Loss of consciousness
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find:
Loss of motor power and sensation in the upper extremities.
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 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?
Maintain a diet for the client that is high in protein, vitamins, and calories.
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?
Maintaining cerebral perfusion pressure from 50 to 70 mm Hg
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?
Meticulous cleanliness
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.
Which of the following is the most common cause of spinal cord injury (SCI)?
Motor vehicle crashes
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?
Paresthesia
A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?
Place the client in a sitting position.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
Pulse and blood pressure
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?
Raise the head of the bed and place the patient in a sitting position.
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?
Rebound hypotension
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 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
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?
A small amount of yellow drainage at the left pin insertion site
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?
An area of bruising over the mastoid bone
The client has been brought to the Emergency Department by their caregiver. The caregiver says that they found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when they came on shift. What are these symptoms indicative of?
Autonomic dysreflexia
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
Which of the following types of skull fractures may be evident by Battle's sign?
Basilar
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter
Which of the following is inconsistent as a cardinal sign of brain death?
No brain waves
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
Observe for any signs of behavioral changes.
Which of the following are characteristics of autonomic dysreflexia?
Severe hypertension, slow heart rate, pounding headache, sweating
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:
raccoon's eyes and Battle sign.
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
vomits
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
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
A male client on a neurologic unit is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for his condition, he is unable to move his lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Expected outcomes of care would include all of the following, except?
Client maintains mechanical ventilation with minimal mucus accumulation.
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?
Conception is not impaired; the birth process is determined with the physician.
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
While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have?
Grade 3 concussion
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and 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.
A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?
Keep the client's neck in a neutral position (no flexing).
Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?
Spasticity
Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?
Subdural hematoma
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?
Suction the airway.
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 their family?
Sweating
The nurse received the 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?
The client has cerebral spinal fluid (CSF) leaking from the ear.
A client has been brought to the Emergency Department (ED) after a fall off a roof. The client has no cord function below the point of injury. The ED nurse knows what about this client?
The client is in spinal shock.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
The Monro-Kellie hypothesis refers to which of the following?
The dynamic equilibrium of cranial contents
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
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?
Widened pulse pressure
A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as
coma
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:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
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?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.