Chapter 68 Neuro

A patient is in the acute phase of an ischemic stroke. How long does the nurse know that this phase may last?

1-3 days

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

HOB 30 degrees

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

A client is hospitalized when presenting to the emergency department with right-sided weakness. Within 6 hours of being admitted, the neurologic deficits had resolved and the client was back to his presymptomatic state. The nurse caring for the client knows that the probable cause of the neurologic deficit was what?

Transient ischemic attack

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

absence of reflexes along with flaccid extremities

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

acute

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?

an area of bruising over the mastoid bone

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?

meticulous cleanliness

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

motor vehicle crashes

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

apply elastic stockings to lower extremities

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

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

insertion of NGT

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

spasticity

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

verbal response, eye opening, motor response

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

vomits

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?

I can apply powder under the liner to help with sweating

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 neuro status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

drug use, alcohol use, young age, male gender

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

suction the airway

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?

temperature increase even 1 degree

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 should the nurse explain differentiates the two disorders?

the first thoracic vertebrae

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

the pt has CSF leaking from the ear

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

they help to prevent the development of contractures

When communicating with a client who has sensory (receptive) aphasia, the nurse should:

use short, simple sentences

A client has just been diagnosed with an aneurysm. In planning discharge teaching for this client, what instructions should be delivered by the nurse to the client?

avoid heavy lifting

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?

basilar skull fracture

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

because hypoxemia can create or worsen a neuro deficit of the spinal cord

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

body temperature

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

change in LOC

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?

monitoring is needed as rapid neurologic deterioration may occur

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

neuro exam

The nurse is caring for a client following an aneurysm coiling procedure. The nurse documents that the client is experiencing Korsakoff syndrome. Which set of symptoms characterizes Korsakoff syndrome?

psychosis, disorientation, delirium, insonnia, and hallucinations

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon eyes and battle sign

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

record I&Os

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

risk for Injury

Which are characteristics of autonomic dysreflexia?

severe HTN, slow HR, pounding headache, sweating

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

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

spinal shock

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

subdural

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?

burr holes

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

epidural hematoma

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.

hypotension, venous pooling, tachypnea, hypothermia

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.

infection, cerebral edema, seizures, hyperthermia, ischemia

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

insertion of an NGT

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?

irrigate the wound to remove the debris

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

it results from initial damage to the brain from the traumatic event

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

keep the client's neck in a neutral position -> no flexing

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

look for signs of increased 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