Chapter 63: Management of patients with neurologic trauma

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.

Absence of brainstem reflexes; Apnea; Coma.

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

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

Body Temperature.

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

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

Monitoring the patency of an indwelling urinary catheter

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

Spasticity

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?

[20mL/15mins * 60mins/1hr] = 80mL/hr

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 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