CHAPTER 63 - Management of Patients with Neurologic Trauma

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? 1. Decrease Pulse Rate 2. Increased Respirations 3. Widened Pulse Pressure 3. Bradypnea

3. Widened Pulse Pressure

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

Absence of reflexes along with flaccid extremities

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?

Apply an external urinary sheath catheter

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolic stockings prior to elevation of the head.

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

Body Temperature

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which symptoms are associated with Cushing's triad?

Bradycardia, HTN, Bradypnea

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

CSF leaking from the ear

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

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

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

Spasticity

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal Shock

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?

The help prevent the development of contractures

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increase ICP

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

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

MVA's