PUCH63 NEUROLOGIC TRAUMA PART I

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? A. Have the client avoid physical exertion B. Emphasize complete bed rest C. Look for signs of increased intracranial pressure D. Look for a halo sign

C

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? A. An epidural hematoma B. An extradural hematoma C. An intracerebral hematoma D. A subdural hematoma

C

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 A. reports a headache. B. reports generalized weakness. C. sleeps for short periods of time. D. vomits.

D

A client with a spinal cord injury has full head and neck control when the injury is at which level? A. C1 B. C2 to C3 C. C4 D. C5

D

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? A. Autonomic dysreflexia B. Thrombophlebitis C. Orthostatic hypotension D. Spinal shock

A

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? A. Apply elastic stockings to lower extremities. B. Take care not to jar the bed or cause unnecessary activity. C. Assist the patient with frequent ambulation. D. Elevate patient's head or follow the physician's directive for body position.

A

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. A. Bradycardia B. Hypertension C. Bradypnea D. Hypotension E. Tachycardia

A B C

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. A. Making nursing assessments B. Setting priorities for nursing interventions C. Anticipating needs and complications D. Initiating rehabilitation E. Ensuring that the patient regains full brain function

A B C D

Which are risk factors for spinal cord injury (SCI)? Select all that apply. A. Young age B. Female gender C. Alcohol use D. Drug abuse E. European American ethnicity

A C D

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A. So that the patient will not have a respiratory arrest B. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord C. To increase cerebral perfusion pressure D. To prevent secondary brain injury

B

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)? A. Position the client in the supine position B. Maintain cerebral perfusion pressure from 50 to 70 mm Hg C. Restrain the client, as indicated D. Administer enemas, as needed

B

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? A. Administer opioids to the client B. Apply an external urinary sheath catheter C. Provide a dimly lit room D. Turn and reposition the client every 2 hours

B

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? A. "I will change the vest liner periodically." B. "If a pin becomes detached, I'll notify the surgeon." C. "I can apply powder under the liner to help with sweating." D. "I'll check under the liner for blisters and redness."

C

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? A. Increased pulse B. Increased respirations C. Widened pulse pressure D. Decreased body temperature

C

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? A. Tetraplegia B. Areflexia C. Autonomic dysreflexia D. Paraplegia

C

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: A. Coma B. Absence of brain stem reflexes C. Apnea D. Glasgow Coma Scale of 6

D

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? A. Examine the skin for any area of pressure or irritation. B. Examine the rectum for a fecal mass. C. Empty the bladder immediately. D. Raise the head of the bed and place the patient in a sitting position.

D

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A. Administering zolpidem tartrate (Ambien) B. Assessing laboratory test results as ordered C. Placing the client in Trendelenburg's position D. Monitoring the patency of an indwelling urinary catheter

D

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? A. Maintain a diet for the client that is high in protein, vitamins, and calories. B. Avoid range of motion exercises for the client because of spasms. C. Keep accurate intake and output. D. Watch closely for signs of urinary tract infection.

A

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? A. Irrigates the wound to remove debris B. Administers an oral analgesic for pain C. Administers acetaminophen (Tylenol) for headache D. Shaves the hair around the wound

A

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? A. Place the patient in a sitting position. B. Call the physician. C. Assess the patient for a full bladder. D. Assess the patient for a fecal impaction.

A

Neurological level of spinal cord injury refers to which of the following? A. The lowest level at which sensory and motor function is normal B. The level of the spinal cord transection C. The highest level at which sensory and motor function is normal D. The best possible level of recovery

A

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? A. Insertion of a nasogastric (NG) tube B. Urine testing for acetone C. Serum sodium concentration testing D. Out of bed to the chair three times a day

A

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? A. Decerebrate B. Normal C. Flaccid D. Decorticate

A

Which are characteristics of autonomic dysreflexia? A. severe hypertension, slow heart rate, pounding headache, sweating B. severe hypotension, tachycardia, nausea, flushed skin C. severe hypertension, tachycardia, blurred vision, dry skin D. severe hypotension, slow heart rate, anxiety, dry skin

A

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following are causes of secondary brain injury? Select all that apply. A. Cerebral edema B. Ischemia C. Infection D. Seizures E. Hyperthermia

A B C D E

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A. Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction B. Ineffective cerebral tissue perfusion related to increased intracranial pressure C. Disturbed thought processes related to brain injury D. Ineffective airway clearance related to brain injury

D

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? A. Signs of infection B. Intake and output C. Nutritional status D. Body temperature

D