Chapter 68: Neurologic Trauma

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5 rationale: Desire/have --> 50/80 X 0.8 --> 0.625 X 0.8 = 0.5

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 neurologic deficit of the spinal cord (2046)

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?

Decerebrate (pg. 2038)

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)?

Epidural (pg. 2036)

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern (pg.2051-2052)

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation. p. 2052.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and 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 (pg. 2034). Primary injury: consequence of direct contact to the head/brain during the instant of initial injury, causing extra-cranial focal injuries (contusions, lacerations, external hematomas, and skull fractures), as well as possible focal brain injuries from sudden movement of the brain within the cranial vault (subdural hematoma), concussion, diffuse axonal injury.

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). Page 2046

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 Pg. 2083

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?

Maintain a diet for the client that is high in protein, vitamins, and calories. (p. 2060)

Which is the most common cause of spinal cord injury (SCI)?

Motor Vehicle crashes

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

Risk for injury related to neurologic deficit (Pg. 2036) Characterized by loss of consciousness associated with stupor and confusion. effects of injury, particularly hemorrhage and edema, peak after about 18 to 36 hours. these effects, which can cause secondary effects resulting in increased ICP and possible herniation syndromes, are most pronounced in temporal lobe contusions. patients are most often managed medically with interventions directed toward prevention of additional insults. Deep contusions are more often associated with hemorrhage and destruction of the reticular activating fibers, altering arousal.

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

Subdural hematoma p. 2037.

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

T6 (pg.2057)

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

subdural (Pg.2037)