Trauma/SCI/TBI/ICP NCLEX Questions

A client with a head injury is being monitored for increased intracranial pressure (ICP). His blood pressure is 90/60 mmHG and the ICP is 18 mmHg; therefore his cerebral perfusion pressure (CPP) is: a.) 52 mm Hg b.) 88 mm Hg c.) 48 mm Hg d.) 68 mm Hg

a.) 52 mm Hg Rationale: MAP=Systolic+Diastolic(x2)/3 90+60(2)=210 90+120=210 210/3=70 MAP=70 CCP=MAP-ICP 70-18=52 CCP=52

Which of the following would lead the nurse to suspect that a client with a fracture of the right femur may be developing a fat embolus? a.) Acute respiratory distress syndrome b.) Migraine like headaches c.) Numbness in the right leg d.) Muscle spasms in the right thigh

a.) Acute respiratory distress syndrome

A patient is admitted with a subacute subdural hematoma. The nurse realizes this patient will most likely be treated with: a.) Emergency craniotomy. b.) Elective draining of the hematoma. c.) Burr holes to remove the hematoma. d.) Removal of the affected cranial lobe.

b.) Elective draining of the hematoma.

Problems with memory and learning would relate to which of the following lobes? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

d.) Temporal Rationale: The temporal lobe functions to regulate memory and learning problems because of the integration of the hippocampus. The frontal lobe primarily functions to regulate thinking, planning, and judgment. The occipital lobe functions regulate vision. The parietal lobe primarily functions with sensory function.

You are working in the triage area of an ED, and four patients approach the triage desk at the same time. List the order in which you will assess these patients: a. An ambulatory, dazed 25-year-old male with a bandaged head wound b. An irritable infant with a fever, petechiae, and nuchal rigidity c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity d. A 50-year-old female with moderate abdominal pain and occasional vomiting. 1.) A B D C 2.) B A D C 3.) C D B A 4.) C B A D

2.) B A D C Rationale: An irritable infant with fever and petechiae should be further assessed for other meningeal signs. The patient with the head wound needs additional history and assessment for intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if necessary.

You respond to a call for help from the ED waiting room. There is an elderly patient lying on the floor. List the order for the actions that you must perform. a. Perform the chin lift or jaw thrust maneuver. b. Establish unresponsiveness. c. Initiate cardiopulmonary resuscitation (CPR). d. Call for help and activate the code team. e. Instruct a nursing assistant to get the crash cart. 1.) A B C E D 2.) B D A C E 3.) C A B E D 4.) D C B E A 5.) E C D B A

2.) B D A C E Rationale: Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.) If the patient is unresponsive, get help and have someone initiate the code. Performing the chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic efforts have been exhausted. A crash cart should be at the site when the code team arrives; however, basic CPR can be effectively performed until the team arrives.

A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis? A.) The client reports pain in the affected leg B.) A large hematoma is visible in the affected extremity C.) The affected extremity is shortened, adducted, and extremely rotated D.) The affected extremity is edematous

C.) The affected extremity is shortened, adducted, and extremely rotated

A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make? A.) Observe the color of the fingers B.) Palpate the radial pulse under the cast C.) Check the cast for odor and drainage D.) Evaluate the response to analgesics

D.) Evaluate the response to analgesics

Based on the nurse's understanding of the physiology of bone and cartilage, the injury that the nurse would expect to heal most rapidly is a: a. fracture of the midhumerus. b. torn knee cruciate ligament. c. fractured nose. d. severely sprained ankle.

a. fracture of the midhumerus. Rationale: Bone is dynamic tissue that is continually growing. Nasal fracture, sprains, and ligament tears injure cartilage, tendons, and ligaments, which are slower to heal.

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits: a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15

a.) A positive Brudzinski's sign Rationale: Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b.) Emergent; the client is poorly oxygenated. c.) Normal d.) Significant; the client has alveolar hypoventilation.

a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Rationale: A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing? a.) Central cord syndrome b.) Whiplash syndrome c.) Anterior cord syndrome d.) Brown-Sequard syndrome

a.) Central cord syndrome Rationale: In central cord syndrome, motor and sensory function of the upper extremities is lost while the functioning of the lower extremities stays intact.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

a.) Evaluate urine specific gravity Rationale: Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

Which of the following would lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation (DIC)? a.) Hemorrhagic skin rash b.) Edema c.) Cyanosis d.) Dyspnea on exertion

a.) Hemorrhagic skin rash Rationale: DIC is characterized by skin petechiae and a purpuric skin rash caused by spontaneous bleeding into the tissues. An abnormal coagulation phenomenon causes the condition.

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space

a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

a.) Normal saline. Rationale: A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

a.) Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

A client with trauma to the chest develops a tension pneumothorax. After a needle thorocostomy is performed the nurse would expect: a.) an increase in blood pressure. b.) a decrease in blood pressure. c.) an increase in jugular venous distension. d.) a decrease in level of consciousness.

a.) an increase in blood pressure. Rationale: Clients presenting with tension pneumothorax would exhibit hypotension, jugular venous distension, and decreasing level of consciousness. An increase in blood pressure should result after a thoracostomy is performed.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracrainal hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent

a.) hypoventilation Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.

When the health care provider tells a patient that the pain in the patient's knee is caused by bursitis, the patient asks the nurse to explain just what bursitis is. The nurse's best response would be to tell the patient bursitis is an inflammation of a. the fibrocartilage that acts as a shock absorber in the knee joint. b. a small, fluid-filled sac found at many joints. c. any connective tissue that is found supporting the joints of the body. d. the synovial membrane that lines the area between two bones of a joint.

b. a small, fluid-filled sac found at many joints. Rationale: Bursae are fluid-filled sacs that cushion joints and bony prominences. Fibrocartilage is a solid tissue that cushions some joints. Bursae are a specific type of connective tissue. The synovial membrane lines many joints but is not a bursa.

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.

b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. Rationale: A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF)

b.) Intracranial pressure (ICP) is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? a.) Absence of pain sensation in chest b.) Spasticity c.) Spontaneous respirations d.) Urinary continence

b.) Spasticity Rationale: Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

The client with an old C6 spinal cord injury complains of suddenly being too warm, with nasal congestion and a very red face. What is your next assessment? a.) temperature b.) blood pressure c.) input and output for previous 8 hours d.) bowel for impaction

b.) blood pressure Rationale: This is autonomic dysreflexia and is usually associated with hypertension. Sit them up quickly.

During an assessment of a patient's motor status with the Glasgow Coma scale, the patient assumes a posture of abnormal flexion. The nurse would document this finding as: a.) 5 b.) 4 c.) 3 d.) 2

c.) 3

A nurse is assisting with caloric testing of the oculovestibular reflex of an unconscious client. Cold water is injected into the left auditory canal. The client exhibits eye conjugate movements toward the left followed by a rapid nystagmus toward the right. The nurse understands that this indicates the client has: a.) A cerebral lesion b.) A temporal lesion c.) An intact brainstem d.) Brain death

c.) An intact brainstem Rationale: Caloric testing provides information about differentiating between cerebellar and brainstem lesions. After determining patency of the ear canal, cold or warm water is injected in the auditory canal. A normal response that indicates intact function of cranial nerves III, IV, and VIII is conjugate eye movements toward the side being irrigated, followed by rapid nystagmus to the opposite side. Absent or dysconjugate eye movements indicate brainstem damage.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? a.) An interval when the client's speech is garbled b.) An interval when the client is alert but can't recall recent events c.) An interval when the client is oriented but then becomes somnolent d.) An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

c.) An interval when the client is oriented but then becomes somnolent Rationale: A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can't recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.

In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment Rationale: A brief neurologic assessment to determine level of consciousness and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

A client with a spinal cord injury is exhibiting poikilothermia. Which of the following would be appropriate to include in this client's plan of care? a.) Provide good perineal care. b.) Pass nasogastric tube to decompress stomach. c.) Keep client warm with extra blankets. d) Stimulate the anal-rectal reflex.

c.) Keep client warm with extra blankets. Rationale: Poikilothermia is a loss of temperature control and is dangerous because the client's body temperature will depend upon the temperature in the environment. The client needs to be kept warm and monitored carefully to avoid thermal injuries from passive warming devices.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care? a.) No precautions are required as long as antibiotics have been started b.) Maintain enteric precautions c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics d.) Maintain neutropenic precautions

c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics Rationale: A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

c.) Parietal Rationale: The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment, and the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a.) Prevent respiratory alkalosis. b.) Lower arterial pH. c.) Promote carbon dioxide elimination. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c.) Promote carbon dioxide elimination. Rationale: The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.

When admitting a client with a fractured extremity, the nurse would focus the assessment on which of the following first? a.) The area proximal to the fracture b.) The actual fracture site c.) The area distal to the fracture d.) The opposite extremity for baseline comparison

c.) The area distal to the fracture

A client with a subdural hematoma becomes restless and confused, with dilation of the ipsilateral pupil. The physician orders mannitol for which of the following reasons? a.) To reduce intraocular pressure b.) To prevent acute tubular necrosis c.) To promote osmotic diuresis to decrease ICP d.) To draw water into the vascular system to increase blood pressure

c.) To promote osmotic diuresis to decrease ICP Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient, drawing fluid from intracellular to intravascular spaces. Although mannitol is used for all the reasons described, the reduction of ICP in this client is a concern.

Following x-rays of an injured wrist, the patient is informed that it is badly sprained. In teaching the patient to care for the injury, the nurse tells the patient to a.) apply a heating pad to reduce muscle spasms. b.) wear an elastic compression bandage continuously. c.) use pillows to keep the arm elevated above the heart. d.) gently exercise the joint to prevent muscle shortening.

c.) use pillows to keep the arm elevated above the heart. Rationale: Elevation of the arm will reduce the amount of swelling and pain. For the first 24 to 48 hours, cold packs are used to reduce swelling. Compression bandages are not left on continuously. The wrist should be rested and kept immobile to prevent further swelling or injury.

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: a.) Acceleration b.) Penetrating c.) Rotational d.) Deceleration

d.) Deceleration Rationale: Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.

The nurse is assessing the motor function of an unconscious client. The nurse would plan to use which of the following to test the client's peripheral response to pain? a.) Sternal rub b.) Pressure on the orbital rim c.) Squeezing the sternocleidomastoid muscle d.) Nail bed pressure

d.) Nail bed pressure Rationale: Motor testing on the unconscious client can be done only by testing response to painful stimuli. Nailbed pressure tests a basic peripheral response. Cerebral responses to pain are testing using sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? a.) Place the client flat in bed b.) Assess patency of the indwelling urinary catheter c.) Give one SL nitroglycerin tablet d.) Raise the head of the bed immediately to 90 degrees

d.) Raise the head of the bed immediately to 90 degrees Rationale: Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia.

A client with a C4 spinal injury would most likely have which of the following symptoms? a.) Aphasia b.) Hemiparesis c.) Paraplegia d.) Tetraplegia

d.) Tetraplegia Rationale: Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.

A patient with a fractured pelvis is initially treated with bed rest with no turning from side to side permitted. The second day after admission, the patient develops chest pain, tachypnea, and tachycardia. The nurse determines that the patient's symptoms are most likely related to fat embolism when assessment of the patient reveals a.) a blood pressure of 100/65 mm Hg. b.) anxiety, restlessness, and confusion. c.) warm, reddened areas in the calf. d.) pinpoint red areas on the upper chest.

d.) pinpoint red areas on the upper chest. Rationale: The presence of petechiae helps distinguish fat embolism from other problems. The other symptoms might occur with fat embolism but could also occur with other postoperative complications such as bleeding, myocardial infarction, venous thrombosis, or hypoxemia.