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A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The nurse should monitor the client for which of the following complications? (Select all that apply.) A. Hypotension B. Polyuria C. Hyperthermia D. Absence of bowel sounds E. Weakened gag reflex

A, D, E

A nurse is caring for a client who has sustained a traumatic brain injury. The nurse should monitor the client for which of the following manifestations of increased intracranial pressure? A. Decreased level of consciousness B. Tachypnea C. Bilateral weakness of extremities D. Hypotension

A. Decreased level of consciousness

A nurse is caring for a client following surgical treatment for a supratentorial brain tumor. Which of the following interventions should the nurse take? A. Elevate the head of the bed to 30°. B. Notify the provider for drainage greater than 80 mL/8hr. C. Place the client in a flat, lateral position. D. Provide passive range-of-motion exercises to the neck.

A. Elevate the head of the bed to 30°.

A nurse is collecting data from a client who is 6 days post craniotomy for removal of an intracerebral aneurysm. The nurse should monitor the client for which of the following manifestationsof increased intracranial pressure? A) Decreased pedal pulses B) Hypertension C) Peripheral edema D) Diarrhea

B) Hypertension

A nurse is caring for a client who has an intracranial pressure (ICP) reading of 40 mm Hg. Which of the following findings should the nurse identify as a late sign of ICP? (Select all that apply.) A. Confusion B. Bradycardia C. Hypotension D. Nonreactive dilated pupils E. Slurred speech

B, D

A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected? A. Pushes the painful stimulus away B. Extends her body toward the painful stimulus C. Shows no reaction to the painful stimulus D. Flexes the upper and extends the lower extremities in response to the painful stimulus

A. Pushes the painful stimulus away

A nurse is assessing an adult who has meningococcal meningitis. Which of the following is an appropriate finding by the nurse? A. Severe headache B. Bradycardia C. Increased muscle tone D. Oriented to time, person, place

A. Severe headache

A nurse is monitoring a client who has a leaking cerebral aneurysm. Which of the following manifestations should indicate to the nurse the client is experiencing an increase in intracranial pressure (ICP)? (Select all that apply.) A. Headache B. Neck pain and stiffness C. Slurred speech D. Pupillary changes E. Disorientation

A,C,D,E

A nurse is caring for a client who has a mild traumatic brain injury (TBI). Which of the following manifestations should the nurse immediately report to the provider? A. A change in the Glasgow Coma Scale score from 13 to 11 B. Diplopia C. A drop in heart rate from 76 to 70/min D. Ataxia

A. A change in the Glasgow Coma Scale score from 13 to 11

A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to monitor C4 function? A. Apply downward pressure while the client shrugs his shoulders upward. B. Apply resistance while the client lifts his legs from the bed. C. Ask the client to grasp an object and form a fist. D. Apply resistance while the client flexes his arms.

A. Apply downward pressure while the client shrugs his shoulders upward.

A nurse is assessing a client who has meningitis and notes when passively flexing the client's neck there is an involuntary flexion of both legs. Which of the following conditions is the client displaying? A. Kernig's sign B. Nuchal rigidity C. Brudzinski sign D. Bradykinesia

C. Brudzinski sign

A nurse is planning care for a female client who has a T4 spinal cord injury and is at risk for acquiring urinary tract infections. Which of the following actions should the nurse include in the client's plan of care? A. Cleanse the perineum from back to front. B. Obtain a prescription for an indwelling urinary catheter. C. Encourage fluid intake at and between meals. D. Offer the client the bedpan every 2 hr.

C. Encourage fluid intake at and between meals.

A home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. Which of the following client statements indicate the client is adapting? A. "My wife tries to get me to go to the grocery store, but I don't like to go out much." B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better." C. "My greatest pleasure each day is having a few beers every day." D. "I have all the equipment to take a shower, but I prefer a bed bath, because it is easier."

B. "I am using the modified feeding utensils at every meal. I still spill, but I'm getting better."

A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make? A. "Turn the screws on the device once each day." B. "The purpose of this device is to immobilize the cervical spine." C. "Apply talcum powder under the vest to limit friction." D. "The purpose of this device is to allow for neck movement during the healing process."

B. "The purpose of this device is to immobilize the cervical spine."

A nurse in an emergency department is caring for a client who had a seizure and became unresponsive after stating she had a sudden, severe headache and vomiting. The client's vital signs are as follows: blood pressure of 198/110 mm Hg, pulse of 82/min, respirations of 24/min, and a temperature of 38.2° C (100.8° F). Which of the following neurologic disorders should the nurse suspect? A. Transient ischemic attack (TIA) B. Hemorrhagic stroke C. Thrombotic stroke D. Embolic stroke

B. Hemorrhagic stroke

A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider? A. Edematous bruise on forehead B. Small drops of clear fluid in left ear C. Pupils are 4 mm and reactive to light D. Glasgow Coma Scale (GCS) score of 12

B. Small drops of clear fluid in left ear

A nurse is caring for a client who has a T-4 spinal cord injury. Which of the following client findings should the nurse identify as an indication the client is at risk for experiencing autonomic dysreflexia? A. The client states having a severe headache. B. The client's bladder becomes distended. C. The client's blood pressure becomes elevated. D. The client states having nasal congestion.

B. The client's bladder becomes distended.

A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.) A. Massage over erythematous bony prominences. B. Implement turning schedule every 4 hr. C. Use pillows to keep heels off the bed surface. D. Keep the client's skin dry with powder. E. Minimize skin exposure to moisture.

C, E

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Administer a nitrate antihypertensive. B. Assess the client for bladder distention. C. Place the client in a high-Fowler's position. D. Obtain the client's heart rate.

C. Plae the client in high-Fowler's position

A nurse is caring for a client who is unconscious following a cerebral hemorrhage. Which of the following nursing interventions is of highest priority? A. Perform passive range of motion on each extremity. B. Monitor the client's electrolyte levels. C. Suction saliva from the client's mouth. D. Record the client's intake and output.

C. Suction saliva from the client's mouth.

A nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of C5. Which of the following rehabilitation goals should the nurse add to the client's plan of care? A. Ability to achieve independent transfer from bed to wheelchair B. Independent control of bowel and bladder function C. Use of a wheelchair with a chin or mouth stick D. Ability to self-feed with the use of adaptive equipment

D. Ability to self-feed with the use of adaptive equipment

A nurse on the intensive care unit is caring for a client who has severe traumatic brain injury and a cerebral perfusion pressure (CPP) of 59 mm Hg. Which of the following actions should the nurse take? A. Provide warming measures for the client. B. Hyperextend the client's neck. C. Flex the client's hip. D. Adjust the client's head of bed

D. Adjust the client's head of bed

A nurse in the emergency room is assessing a client who was brought in following a seizure. The nurse suspects the client may have meningococcal meningitis when assessment findings include nuchal rigidity and a petechial rash. After implementing droplet precautions, which of the following actions should the nurse initiate next? A. Complete a vascular assessment. B. Administer an antipyretic. C.Decrease environmental stimuli. D. Assess the cranial nerves.

D. Assess the cranial nerves.

A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take? A. Inform the client that privileges are related to participation in therapy. B. Limit visiting hours until the client begins to participate in therapy. C. Allow the client to control the timing and frequency of the therapy. D. Establish a plan of care with the client that sets attainable goals.

D. Establish a plan of care with the client that sets attainable goals.

A nurse is caring for a client who has a traumatic head injury and is exhibiting signs of increasing intracranial pressure. Which of the following medications should the nurse plan to administer? A. Albumin 25% B. Dextran 70 C. Hydroxyethyl glucose D. Mannitol 25%

D. Mannitol 25%

A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability? A. Paresthesia B. Hemiplegia C. Quadriplegia D. Paraplegia

D. Paraplegia

A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic dysreflexia. Which of the following actions should the nurse take first? A. Check the client for a fecal impaction. B. Examine the client for areas of skin breakdown. C. Check the client's bladder for distention. D. Place the client in a sitting position.

D. Place the client in a sitting position.

A nurse is caring for a client who has a traumatic brain injury. Which of the following findings should the nurse identify as an indication of increased intracranial pressure (ICP)? A. Tachycardia B. Amnesia C. Hypotension D. Restlessness

D. Restlessness

A nurse is caring for a client who has increased intracranial pressure (ICP) following a closed-head injury. Which of the following actions should the nurse take? A. Instruct the client to cough and deep breathe. B. Place the client in a supine position. C. Place a warming blanket on the client. D. Use log rolling to reposition the client.

D. Use log rolling to reposition the client.