PrepU 68
At the level of C5
, the patient should have full head and neck control, shoulder strength, and elbow flexion.
Risk for injury related to neurologic deficit
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Immediate craniotomy
A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?
sweating
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?
vomit
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
An intracerebral hematoma
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?
It allows for stabilization of the cervical spine along with early ambulation.
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?
Bradycardia Hypertension Bradypnea
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.
C5
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5..
At which of the following spinal cord injury levels does the patient have full head and neck control?
spinal cord injury.
Autonomic dysreflexia and respiratory infection are long-term complications of
T6
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
Raise the head of the bed and place the patient in a sitting position.
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?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
a neurologic deficit of the spinal cord.
Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen
At C1 injury
PT has little or no sensation or control of the head and neck.
Meticulous cleanliness
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?
of spinal cord injury.
Respiratory arrest and spinal shock (areflexia) are immediate complications
The dynamic equilibrium of cranial contents
The Monro-Kellie hypothesis refers to which of the following?
coma.
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
Young age Alcohol use Drug abuse
Which are risk factors for spinal cord injury (SCI)? Select all that apply.
spasticity.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
Occipital skull fracture
a break of a bone in the base of the skull. Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear
The three cardinal signs of brain death on clinical examination are
coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.
Nociceptive pain
detected by specialized sensory nerves located throughout the soft tissues and is not neurogenic.
Secondary injury
evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia.
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.
coma
state of profound unconsciousness
Monro-Kellie hypothesis
states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others.
At C4 injury,
the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement.
At C2 to C3,
the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
Hyperalgesia
type of neurogenic pain whereby clients experience an increased response to a painful stimulus.
Allodynia
type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus.
take daily weights
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?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.
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?
client maintains mechanical ventilation with minimal mucus accumulation
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
Paresthesia
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?
Place the client in a sitting position.
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?
Look for signs of increased intracranial pressure
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
C5.
A client with a spinal cord injury has full head and neck control when the injury is at which level?
Fever and change in urine clarity
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?
Absence of reflexes along with flaccid extremities
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Contusion (bruise)
A large patch of capillary bleeding into tissues. Color is red-blue or purple immediately after or within 24hrs >blue to purple>blue-green> yellow >brown-disappearing. Bruise in dark skinned is deep dark purple. Pressure on bruise does not cause it to blanch
severe TBI
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:
Glasgow Coma Scale of 6
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:
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.
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:
Monitoring is needed as rapid neurologic deterioration may occur.
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?
Epidural hematoma
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?
Irrigates the wound to remove debris
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?
basilar
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?
Cerebral edema Ischemia Infection Seizures Hyperthermia
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.
Autonomic dysreflexia.
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?
A change in consciousness.
The earliest sign of serious impairment of brain circulation related to increased ICP is:
Basilar skull fracture
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?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?
Hypertension Diaphoresis Nasal congestion
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.
"I can apply powder under the liner to help with sweating."
The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?
Temperature increase from 98.0°F to 99.6°F
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?
Burr holes
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?
Edema to the head with bruising of the mastoid process
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?
The first thoracic vertebrae
The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?
The client has cerebral spinal fluid (CSF) leaking from the ear.
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?
An area of bruising over the mastoid bone
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?
It results from inadequate delivery of nutrients and oxygen to the cells.
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?
Ecchymosis over the mastoid
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?
Offer encouragement as the client makes progress. Involve the client actively in self care.
There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply.
famotidine (Pepcid).
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:
hmm
Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of 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.
body temperature
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?
decerebrate
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?
severe hypertension, slow heart rate, pounding headache, sweating
Which are characteristics of autonomic dysreflexia?
autonomic dysreflexia respiratory infection
Which are possible long-term complications of spinal cord injury? Select all that apply.
Subdural hematoma
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Widened pulse pressure
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Motor vehicle crashes
Which is the most common cause of spinal cord injury (SCI)?
Monitoring the patency of an indwelling urinary catheter
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Tachycardia
Which of the following is NOT a manifestation of Cushing's triad (Cushing reflex)?
Change in level of consciousness (LOC)
Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?
Apply elastic stockings to lower extremities.
Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.
Grade 3 concussion
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?
concussion
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
Autonomic dysreflexia
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?
Frontal skull fracture
a break of a bone in the base of the skull. Symptoms may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear.
Autonomic dysreflexia is
an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
concussion.
an injury of a soft structure, as the brain, resulting from a blow or violent shaking,
A concussion results
from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.
Idiopathic pain
has no apparent underlying cause and is not neurogenic.
Tetraplegia
is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae.
Paraplegia
is the impairment of all extremities below the first thoracic vertebrae.
Temporal skull fracture
may include bruising behind the ears, bruising around the eyes, or blood behind the ear drum. A cerebrospinal fluid (CSF) leak occurs in about 20% of cases and can result in fluid leaking from the nose or ear.
Cushing's triad, or Cushing reflex
nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.
spasticity
often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes..
Persistent vegetative state
phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function
Cushing's response
phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure.
Akinetic mutism
phrase used to refer to unresponsiveness to the environment.
ataxia
refers to impaired ability to coordinate movement.
akathisia
refers to restlessness, an urgent need to move around, and agitation.
Myoclonus
refers to spasm of a single muscle or group of muscles.
