Med-Surg Ch 22: Care of Patients With Head and Spinal Cord Injuries

Which statement by a high school athlete being discharged after experiencing a concussion indicates a need for more teaching? A. "I can go to football practice tomorrow." B. "I need to report a worsening heachache to the health care provider." C. "I need to rest and not overdo activities." D. "I can expect to be more fatigued for a while."

"I can go to football practice tomorrow." *Any patient with a concussion should rest for 48 hours after the injury, and teenagers may take longer. The student may not return to practice or play until a health care provider's release is obtained. (2, 3, 4) These are commonly recommended practices and indications.

The patient who had a laminectomy following a herniated lumbar disk is preparing to be discharged. Which statement by the patient indicates a need for additional discharge instructions? A. "I need to be sure not to twist or bend at the waist when lifting things." B. "I should try to maintain a normal weight." C. "I can take a 4 h car ride, as long as I stay perfectly still." D. "It is best for me to do my back exercises twice a day."

"I can take a 4 h car ride, as long as I stay perfectly still." *Standing and sitting for long periods is discouraged for several weeks following a laminectomy; the patient should be encouraged to stop and walk around at least every 2 h. The patient would be correct in stating he should try to maintain a normal weight, do back exercises twice a day, and avoid twisting or bending at the waist when lifting.

A patient with a daughter who is engaged to be married suffered an accident that left him paraplegic. What comment indicates the patient is in the stage of bargaining? A. "I am saddened that I will miss being able to dance with my daughter at her wedding." B. "I do not deserve to be paralyzed for my daughter's wedding!" C. "If God will let me just walk my daughter down the aisle for her wedding, I'll never complain about being in this chair again!" D. "Maybe I will be able to have special braces so that I will be able to operate a Segway as a way of 'walking' my daughter down the aisle."

"If God will let me just walk my daughter down the aisle for her wedding, I'll never complain about being in this chair again!"

The nurse is caring for an adolescent who has lower limb paralysis after sustaining a spinal injury yesterday. The patient's anxious mother asks if the paralysis is permanent. Which response is most appropriate for the nurse to make? A. "It is possible that motor function may or may not return after spinal cord swelling has subsided." B. "Motor function may improve, but there will always be a deficit." C. "In all likelihood, the paralysis will be permanent. D. "Have you asked the physician about your concerns?"

"It is possible that motor function may or may not return after spinal cord swelling has subsided." *Until spinal cord edema has subsided, the extent or the permanency of the paralysis cannont be evaluated. It would be incorrect to indicate that there will definately be a deficit or paralyisis. Not addressing the question and suggesting only to talk to the physician will likely frighten the parent

A 75-year-old patient who fell and hit his head a week ago is admitted for apparent personality changes, decreased level of consciousness, and irritability. The health care provider suspects a possible subdural hematoma. A family member asks about the condition. An accurate explanation would be A. "It is the presence of bleeding in the brain parechyma." B. "Bleeding occurs between the skull and the dura mater." C. "It is the collection of blood between the brain and the inner surface of the dura mater." D. "It is the intermittent blockage of circulation in various areas of the brain."

"It is the collection of blood between the brain and the inner surface of the dura mater." *A subdural hematoma occurs beneath the dura, between the brain and the dura. (1) The parenchyma is not between the brain and the inner surface of the dura mater. (2) The bleeding is on the other side of the dura mater. (4). A hematoma is not intermittent and occurs in a specific location.

The surgeon inserts an intraventricular catheter into the lateral ventricle of a patient with increased ICP. When asked by a relative about the procedure, an accurate response would be A. "The catheter allows direct visualization of the brain tissue." B. "The catheter is used to monitor brain waves." C. "The catheter is used to remove excess fluid inside the brain." D. "The catheter is used to infuse fluids and medications into the brain."

"The catheter is used to remove excess fluid inside the brain." *An intraventricular catheter is used to drain off excess cerebral spinal fluid and monitor ICP. (1) The catheter does not allow visualization of the brain tissue. (2) The catheter does not have a mechanism to monitor brain waves. (4). Fluids and medications are not infused into the brain through the intraventricular catheter.

The nurse is caring for a patient wil flaccid paralysis after sustaining a spinal cord injury 3 days earlier. The family excitedly notifies the nurse that the patient has flexed his arm. Which response is best for the nurse to make? A. "I will give the doctor this wonderful news." B. "Avoid directly touching the arm muscles so that you don't cause more muscle spasms." C. "This movement means that the spinal cord is adjusting to the injury." D. "These muscle spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries."

"These muscle spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries." *The patient is experiencing the spastic phases of paralysis that occurs as the cord adjusts to injury. The family members may interpret these spasms as a return of voluntary limb function and an indicator of impending complete recovery. First, the nurse should explain that this movement is not purposeful and an expected finding that often occurs in patients with spinal cord injuries

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (select all that apply) A. An epidural hematoma is related to bleeding from arterial venous source B. An epidural hematoma can increase intracranial pressure (ICP) quickly C. An epidural hematoma changes overall condition quickly D. An epidural hematoma can cause death E. An epidural hematoma can cause irreversible brain damage

1. An epidural hematoma can increase intracranial pressure (ICP) quickly 2. An epidural hematoma changes overall condition quickly 3. An epidural hematoma can cause death 4. An epidural hematoma can cause irreversible brain damage *An epidural hematoma can increase ICP quickly, changes overall condition quickly, and can cause death or irreversible brain damage. Bleeding is related to an arterial source. An epidural hematoms is a medical emergency

A nurse is admitting a patient with a possible basilar skull fracture. Which clinical finding(s) would likely confirm the diagnosis? (select all that apply) A. Battle sign B. Partial blindness C. Eccchymosis around eyes D. Rhinorrhea E. Swallowing difficulty

1. Battle sign 2. Ecchymosis around eyes 3. Rhinorrhea *Clinical signs of a basilar skull fracture include Battle sign, ecchymosis around the eyes, and rhinorrhea. (2) Partial blindness and (5) swallowing difficulty are not signs of basilar skull fracture.

The nurse is caring for a patient with autonomic dysreflexia (AD). The nurse should assess the patient for which conditions or situations? (Select all that apply) A. Distended bladder B. Constipation C. Increased fluid intake D. Wrinkles in bed linens E. Abrupt environmental temperature changes

1. Distended bladder 2. Constipation 3. Wrinkles in bed linens 4. Abrupt environmental temperature changes *Autonomic dysreflexia (AD) causes a rapid increase in blood pressure. Increased fluid intake is not relevant to AD

After an older adult falls, the nurse suspects the development of a subdural hematoma based on whicih finding(s)? (select all that apply) A. Increasing irritability B. Complaint of a dull headache C. Frequent "nodding off" in chair during the day D. Focal seizures E. Staggering gait

1. Increasing irritability 2. Complaint of a dull headache 3. Frequent "nodding off" in chair during the day *Seizures and staggering gait are not specifically indicative of subdural hematoma

A patient is bought in by ambulance with a suspected head injury. What are the outward symptoms of a skull fracture (Select all that apply.) A. Diarrhea B. Ottorhea C. Tinnitus D. Chvostek sign E. Battle sign

1. Ottorhea 2. Battle sign *The outward symptoms of skull fracture include ottorhea and Battle sign. Diarrhea is not a symptom of head injury. Chvostek sign is used to assess for hypocalcemia. Tinnitus is not an outward sign of skull fracture.

The nurse documents which sign(s) of epidural hematoma in a patient with a closed head injury? (select all that apply) A. Mottling of extremities B. Periorbital ecchymosis C. Battle signs D. Nausea and vomiting E. PERRLA

1. Periorbital ecchymosis 2. Battle signs 3. Nausea and vomiting *Racoon eyes (periorbital ecchymosis), bruising behind the ears (battle sign), and nausea are some of the typical signs of epidural hematoma

The classic signs of increased ICP include which of the following? (select all that apply) A. Rising systolic blood pressure B. Widening pulse pressure C. Bradycardia D. Positive Babinski sign

1. Rising systolic blood pressure 2. Widening pulse pressure 3. Bradycardia *(1, 2, 3) These are the classic signs of increased intracranial pressure (Cushing triad). (4) A positive Babinski sign indicates CNS damage.

The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain. Which activities indicate that the patient adequately understands the nurse's teaching? A. The patient carries items away from the center of the body B. The patient bends the knees, with the back straight, and crouches to lift an item off the floor C. The patient uses a lumbar pillow or roll when sitting for long periods D. The patient performs proper back exercises twice a day E. The patient maintains proper body weight

1. The patient bends the knees, with the back straight, and crouches to lift an item off the floor 2. The patient uses a lumbar pillow or roll when sitting for long periods 3. The patient performs proper back exercises twice a day 4. The patient maintains proper body weight *The patient should carry items close to the center of the body rather than away from the center of the body

The nurse uses a visual air to demonstrate how a coup-contrecoup injures the brain. Which information should the nurse include? (select all that apply) A. These injuries allow the brain to twist on the brainstem B. These injuries cause the brain to move forward to strike the anterior skull C. These injuries allow the brain to compress on itself D. These injuries cause the brain to strike the bony area opposite of the site if impact E. These injuries cause the brain to lose small amounts of cerebrospinal fluid

1. These injuries cause the brain to move forward to strike the anterior skull 2. These injuries cause the brain to strike the bony area opposite of the site if impact *In a coup-contrecoup injury, the brain moves forward, striking the anterior interior wall of the cranium, and moves back, striking the bony area opposite of the impact, causing two areas of injury

The nurse is caring for a patient with a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? A. Transferring himself B. Dressing himself C. Using a wheelchair with standard hand rims D. Feeding himself E. Typing using all digits

1. Transferring himself 2. Dressing himself 3. Using a wheelchair with standard hand rims 4. Feeding himself *With physical and occupational therapy, the patient may be able to transfer himself, dress and feed himself, and use a wheelchair with standard hand rims. The patient with an injury at C7 does not have full control of all digits. The third finger is the most functional

A 40-year-old man with a T4 spinal cord injury suddenly complains of severe headache, increased pulse rate, sweating, flushing above the level of the spinal cord lesion, and "goosebumps" below the level of injury. Which immediate nursing action(s) should be taken? (select all that apply) A. place flat in bed B. identify the cause of stimulation C. Administer ordered antihypertensives D. Loosen tight clothing E. Clamp indwelling catheter

1. identify the cause of stimulation 2. Administer ordered antihypertensives 3. Loosen tight clothing *Identify and gently relieve the cause of the autonomic dysreflexia (AD) reaction. Decrease the blood pressure by administering medications to rapidly reduce blood pressure. Tight clothing can trigger AD. (1, 5) Placing the patient flat in bed and clamping the indwelling catheter will not resolve the problem and may exacerbate it. The head of the bed should be raised to help lower blood pressure, and bladder distention can trigger AD.

Mannitol is an osmotic diuretic that helps decrease ICP. Nursing interventions for the patient receiving this drug include: (Select all that apply.) A. monitor intake and output. B. observe for chest pain. C. monitor for increasing salivation. D. watch for electrolyte imbalances. E. check skin turgor.

1. monitor intake and output. 2. observe for chest pain. 3. watch for electrolyte imbalances. 4. check skin turgor.

Postoperative pain managment for the patient with lumbar surgery may include (select all that apply) A. use of ice packs o the area of back pain for up to 20 minutes each hour while awake for the first 48 hours B. NSAID medications given orally or IV C. Complete bed rest to prevent injurt to the operative area and promote comfort D. Higher dosing of opioids delivered by PCA E. Massage and warm whirlpool baths F. Topical analgesic creams

1. use of ice packs o the area of back pain for up to 20 minutes each hour while awake for the first 48 hours 2. NSAID medications given orally or IV 3. Higher dosing of opioids delivered by PCA *Ice packs can be used for 20 minutes each hour for the first 48 hours to reduce pain and swelling. NSAIDs are nonopioid analgesics that also can reduce inflammation. Chronic opioid use creates a tolerance for the medication. Higher doses are needed to obtain adequate pain control. (3) Complete bed rest is contraindicated and will not promote comfort. (5, 6) Massage, warm whirlpool baths, and topical analgesic creams are all contraindicated with a fresh incision.

The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the carbon dipxide (CO2) should be maintained at what level? A. 10 to 15 mm Hg B. 15 to 20 mm Hg C. 20 to 25 mm Hg D. 25 to 30 mm Hg

25 to 30 mm Hg *The CO2 level is set to be maintained at 25 to 30 mm Hg to create vascular constrictionm raise blood pressure, and perfuse the cerebrum

Mr. Pineda suffered a closed head injury and has increased ICP. The health care provider has prescribed mannitol 1 g/kg IV every 6 hours. Mr. Pineda weighs 194 lbs. How many grams of mannitol would be the correct dose to be given every 6 hours? _____ g

88

The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first? A. Document the presence of rhonorrhea B. Inform the physican of the assessment C. Assess the fluid for a halo sign D. Tape a drip pad under the nose

Assess the fluid for a halo sign *Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a cerebrospinal fluid (CSF leak. Assessing for the halo sign on fluid fromt he nose or ear after a head injury. The blood will draw together in the middle of the gauze pad, leaving a yellow ring (halo) around the blood, indicating the presence of cerebrospinal fluid. Documentation, informing the physician, and applying a drip pad under the nore are actions that should occur after confirmation of the fluid type

Which of the following conditions can increase the risk for torn vessels and contusion on the brain if an accident that involves brain injury occurs? A. Increased intracranial pressure (ICP) B. Heterotopic ossification C. Brain atrophy D. Hydrocephalus

Brain atrophy *Brain atrophy (shrinkage in size) can occur with aging and places the person at risk for torn vessels and contusion on the brain in the event of an accident with brain injury. Increased ICP and hydrocephalus can both provide cushion to the brain in the event of an accident that involves brain injury. Both of those conditions could occur as a result of a brain injury, but they would not place the patient at more risk for torn vessels or contusion on the brain like brain atrophy would. Heterotopic ossification may occur with long-term immobility; this is a bony overgrowth that may involve muscle, and it is considered a long-term complication of spinal injury.

Mary took a fall while skiing and bumped her head on a small tree. She got right up and stated that she was fine. However, shortly afterwards Mary began suffering from a headache. What should her family do? A. Give Mary two Tylenol and see if it resolves the headache. B. Give Mary two ibuprofen because it would help reduce any inflammation Mary is experiencing. C. Call 911 as Mary experienced a head injury earlier and may be developing complications such as a subdural hematoma. D. Wait to see if any other symptoms such as nausea and vomiting develop, and if they do, take her to an urgent care center.

Call 911 as Mary experienced a head injury earlier and may be developing complications such as a subdural hematoma.

The nurse is caring for a patient with a neurologic injury who is awake. On assessment, the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands. The nurse correctly documents the patient's level of consciousness (LOC) by using which term? A. Alert B. Confused C. Lethargic D. Obtunded

Confused *The confused patient is awake, but slightly confused and needs coaching to respond to commands. Alert indicates appropriate response to questions with little stimulation. Lethargic is described as the patient being drowsy, but easily aroused. Obtunded patients are more difficult to arouse and respond slowly to stimulation

The nurse is caring for a patient with a closed head injury. Which finding causes the nurse to suspect that the patient has developed diabetes insipidus (DI)? A. Increased lethargy B. Widening pulse pressure C. Copious pale urine output D. Increasing blood glucose levels

Copious pale urine output *A large increase in urinary output of pale urine with a low specific gravity is the clue to the development of DI related to edema of the posterior pituitary. ADH is released in inadequate amounts, resulting in polyuria, and the awak patient may complain of polydipsia (excessive thirst). IV vasopressin and fluid replacement are the preferred treatments. Lethargy and increased pulse pressure are not typical signs of DI. Increased serum glucise leves are a sign of DM not DI.

The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5 minute peropd of unconciousness. The nurse most carefully monitors the patient for which change? A. Increasing respiratory rate B. Decreasing heart rate C. Decreasing pulse pressure D. Decreasing level of consciousness (LOC)

Decreasing level of consciousness (LOC) *Assessment of LOC provides the greatest amount of information about neurologic condition. A reduction in LOC may signal the onset of complications in the patient who has had a head injury

The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD). Which action is most important for the nurse to take first? A. Elevate the head of the bed B. Notify the charge nurse C. Decrease the IV fluid rate D. Administer anti-hypertensive medication

Elevate the head of the bed *AD (hyperreflexia) response is potentially dangerous to the patient, because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure. Elevating the head of the bed is the initial intervention to decrease the rising blood pressure. The nurse should notify the charge nurse and the physiciam. The IV fluids can be decreased but are not the most important intervention. The vital signs should be obtained and the cause of AD should be addressed before administering any hypertensive medication

Following a craniotomy to relieve increased intracranial pressure (ICP), which implementation should the nurse implement? A. Elevate the head of the bed 20 to 30 degrees B. Place drip pad or cotton to absorb cerebrospinal fluid (CSF) drainage from the nose or ears C. Stimulate the patient to better assess changing level of consciouness (LOC) D. Reposition the patient frequently for comfort

Elevate the head of the bed 20 to 30 degrees *A patent airway must be secured and the head raised 20 to 30 degrees with the body in correct alignment. Elevation helps reduce ICP. Neurologic signs are monitored closely. An IV line is inserted for access for diuretic drugs, if needed, and for administration of fluid. IV fluids are infused very slowly to prevent fluid overload that would increase the ICP. Diuretics are used to decrease vascular volume and keep ICP as low as possible. Drip pads, patient stimulation, and changing positions frequently may increase ICP

After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? A. Tinel sign B. Babinski sign C. Battle sign D. Halo sign

Halo sign *Assessing for the halo sign determines whether drainage from the nose or ear is cerebrospinal fluid. Tinel sign is one assessment used during the assessment of carpal tunnel symptoms. Bruising behind the ear that occurs after a head injury is called Battle sign. Babinski sign is checked as part of a neurologic assessment.

Which position is best for an unconscious patient with a right-sided closed head injury? A. High Fowler B. Right side-lying C. Flat with small pillow under head D. Head of bed 20 to 30 degrees

Head of bed 20 to 30 degrees *Keeping the head of the bed 20 to 30 degrees witht he body in good alignment will help reduce intracranial pressure and keep the airway patent

A patient presents to the health clinic with low back pain that radiates into the buttcks and below the knee. The nurse suspects which condition? A. Herniated disk B. Muscle spams in lower back C. Spinal cord injury D. Sciatica

Herniated disk *Herniated disks typically cause compression on the sciatic nerve and allow the pain to radaite into the buttocks and leg. Muscle spasm in the lower back will result in back pain. There is no indication of spinal cord injury. Pain from sciatica does not involve back pain

An older adult patient has been diagnosed with a herniated disc after suffering a fall at home. What treatment would be anticipated with this patient? A. Complete bed rest for 48 h. B. Surgical intervention within the first 24 h. C. Intense physical therapy within the first 24 h. D. Ice packs applied hourly for the first 48 h.

Ice packs applied hourly for the first 48 h. *Ice packs are applied for 5 to 10 minutes at a time each hour for the first 48 h to reduce muscle spasm in the back. After 48 h, heat may be more helpful, because heat relaxes strained muscles. The provider will treat back pain initially with conservative measures in the hope that surgical correction will not be necessary. If there is no sciatic pain, bed rest is not recommended, because research has shown that walking provides a quicker recovery. When sciatic pain is present, lying down for short periods can help relieve the pain. Standing or lying is recommended rather than sitting which puts pressure on the disks. Physical therapy is not an immediate intervention.

The student nurse is planning care for a patient with a recent spinal cord injury. Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient? A. Keep the halo jacket fastened unless the patient is in a supine position B. Monitor the bladder every 4 h for signs of bladder distention C. Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 h D. Assess compression stockings for proper fit

Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 h *Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed peronnel. Following proper instruction, the UAP can assist the nurse with moving or repositioning the patient. Halo jackets must be kept fastened unless the patient is in a supine position in order to prevent sudden head movement. Bladder distention should be avoided to prevent infection or autonomic dysreflexia. Compression stockings are used to prevent deep vein thrombosis

In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipate that the patient will demonstrate which signs? A. Left-sided hemiplegia with dilated right pupil B. Right sided hemiplegia with brisk right pupil response C. Bilateral motor hemiplegia with bilaterally dilated pupils D. Left-sided hemiplegia and bilateral PERRLA

Left-sided hemiplegia with dilated right pupil *An acute intracerebral bleed causing hematoma formation is accompanied by unconciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil pn the ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure within the skull are more subtle and less easily detected

A nursing assistant is attending to the needs of a patient with a head injury who is lethargic and has increased ICP. Which action by the nursing assistant indicates a need for further instruction? A. Notifying the nurse of patient coughing B. Monitoring blood pressure every shift C. Keeping the patient NPO D. Reporting blood on the dressing

Monitoring blood pressure every shift *A patient who has increased intracranial pressure should have the blood pressure checked every 15 to 30 minutes, not just every shift. (1) Coughing can increase ICP, and the nurse may need to medicate the patient. (3) The nursing assistant should not give anything by mouth to a lethargic patient due to aspiration risk. (4) Any bleeding should be reported to the nurse.

The nurse suspects that a 36-year-old patient recovering from a hypophysectomy (removal of the pituitary gland) has developed diabetes insipidus (DI). What sign or symptom is most indicative of DI? A. Polyuria B. Polyphagia C. Hyperkalemia D. Hypertension

Polyuria *DI results from lack of antidiuretic hormone, which can happen after a hypophysectomy. The combination of polyuria and polyphagia could indicate onset of diabetes mellitus under other circumstances, however. Polyphagia, hypertension, and hyperkalemia are not indicative of DI.

Planning for the patient who has sustained a spinal injury would include listing which nursing problem as the highest priority in the care plan? A. Altered sensory perception due to spinal contusion B. Potential for infection due to trauma to spinal column C. Incontinence due to paraplegia D. Potential for injury due to inability to move

Potential for injury due to inability to move

What is a priority nursing intervention for the patient with a spinal cord injury who is quadriplegic? A. Preventing overdistention of the bladder B. Assessing skin integrity every shift C. Using an abdominal binder to raise blood pressure D. Providing frequent massage of the legs

Preventing overdistention of the bladder

A patient experienced injury to the spinal cord in the cervical region, with paralysis and loss of sensory perception in both legs and both arms. What term is used to describe this condition? A. Paraplegia B. Hemiplegia C. Homoplegia D. Quadriplegia

Quadriplegia *Injury to the spinal cord in the cervical region with paralysis and the loss of sensory perception in both legs and both arms is quadriplegia. Paraplegia is paralysis of both legs. Hemiplegia is paralysis of one half of the body. Homoplegia is not used to describe paralysis in the body.

Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head? A. The 36-year-old patient who has a history of migraine headaches. B. The 16-year-old football player who suffered a concussion. C. The 76-year-old patient who is taking an anticoagulant. D. The 56-year-old patient who is taking an antihypertensive medication.

The 76-year-old patient who is taking an anticoagulant. *A subdural hematoma results when blood leaks under the dura mater (subdural) and presses against the softer arachnoid membrane and the brain tissue it is covering. As blood leaks, the hematoma grows in size. The 76-year-old patient is most at risk for a subdural hematoma due to his anticoagulant medication. The football player who suffered a concussion is at an increased risk for a head bleed, but less so than the elderly patient taking anticoagulant medication. The patients with migraine headaches and antihypertensive medications are not at an increased risk for hemorrhage.

Why is the older adult more at risk for a cranial bleed following a head injury? A. The older adult's brain is smaller, which allows for more movement insude the cranium B. The older adult's brain features fragile vessels more likely to rupture C. The older adult's brain contains less cerebrospinal fluid (CSF) to cushion the brain D. The older adult's brain has less flexible meninges to absorb impact

The older adult's brain is smaller, which allows for more movement insude the cranium *The brain atrophies with age and does not take up as much space inthe cranial vault. This change allows for more movement and more potential for torn vessels and contusions on the brain when an accident occurs that involves a head injury

The nurse describes a concussion as a closed head injury in which A. The brain tissue is bruised B. No loss of consciousness occurs C. There is amnesia related to the incident D. There are no subsequent symptoms

There is amnesia related to the incident *A concussion is a clised head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks

The patient with a suspected subdural hematoma is on an intravenous (IV) drip of mannitol infusing at 50 mL/h. The nurse explains that the slow infusion rate is essential for what purpose? A. To ensure effectiveness of the drug B. To avoid fluid overload C. To maintain electrolyte balance D. To mainatain adequate blood pressure

To avoid fluid overload *The slow infusion rate will not cause fluid overload, which would add to the possibility of increased intracranaial pressure (ICP)

When turning the patient who is in Crutchfield tongs traction, the nurse should employ which technique? A. Turn the patient as a unit by logrolling B. Release the weight sto prevent injury while turning C. Turn the patient quickly to avoid muscle spasms D. Advise the patient to hold his breath and beat down during turning

Turn the patient as a unit by logrolling *Turning the patient as a unit by logrolling with the weights in place immobilizes the affected vertebrae and maintains alignment. Releasing the weights quickly or turning quickly will affect vertebrae and alignment. Deep breathing will decrease muscle tension

The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? A. Support the patient's head with a pillow so that his neck is flexed. B. Flex the knees and hips before turning the patient. C. Turn the patient slowly and as one unit to avoid twisting the spine. D. Place the patient's back in traction so that the spine will be kept slightly flexed.

Turn the patient slowly and as one unit to avoid twisting the spine. *One of the most important interventions when turning a patient in traction, or turning any patient with a spinal cord injury, is to logroll the patient in order to avoid twisting the vertebral column and further damaging the spinal cord. Nurses should always assist in turning a patient with a spinal cord injury; this intervention should never be delegated to assistive personnel.

The nurse is caring for a patient with spastic paralysis. Which technique is most appropriate for the nurse to use when moving the patient? A. Firmly grasp the muscles B. Use the palms of hands to support the joints C. Logroll the patient as a unit D. Perform passive range of motion (ROM)

Use the palms of hands to support the joints *Spastic paralysis features involuntary skeletal muscle contractions. These muscle spasms may be violent enough to throw the patient from the bed or wheelchair and must be anticipated, and the patient must be secured so that accidents can be avoided. To avoid stimulating the muscles when moving the patient and thereby precipitating a spasm of the muscles, the nurse should avoid grasping the muscle itself. Instead, the nurse should use the palms of the hands to support the joints above and below the affected muscles. Firmly grasping the muscles, logrolling, and ROM may initiate spasms

You keep a postcraniotomy patient's neck in midline position and ensure that there is no excessive hip flexion. The rationale for your action would be that this position A. restores neutral position of the joints B. prevents a further increase in intracranial pressure C. promotes comfort and rest D. prevents the formation of blood clots

prevents a further increase in intracranial pressure *Keeping the neck in midline ensures venous drainage from the head; preventing excessive hip flexion prevents increased intrathoracic pressure (Valsalva) and prevents increased intracranial pressure. (1) A neutral position is not necessarily recommended. (3) The midline position may not be comfortable for the patient. (4) The midline position does not prevent formation of blood clots.

Discharge teaching for a patient who has sustained a concussion should include instructions to A. take the prescribed and analgesic for headache every 4 hours B. lie down flat at home and move around as little as possible C. force fluids to prevent dehydration and infection D. report immediately any severe headache of persistent vomiting

report immediately any severe headache of persistent vomiting

Autonomic dysreflexia can lead to: A. heat stroke from loss of thermoregulation. B. paralytic ileus. C. severe muscle cramps. D. severe hypertension.

severe hypertension.

A 30-year-old is admitted to the emergency department after a motor vehicle accident. After examination, the patient is diagnosed with a T6 spinal cord injury. He has flaccid paralysis, slowed heart rate, low blood pressure, and no bowel sounds. The patient must be developing A. autonomic dysreflexia B. muscle spasms C. spinal shock D. diabetes indipidus

spinal shock *Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. (1) Autonomic dysreflexia is characterized by excessively high blood pressure. (2) Muscle spasms cause pain in muscular areas. (4) Diabetes insipidus is characterized by excessive thirst and excretion of large amounts of severely dilute urine.

The first priority in assessing the patient with head trauma at an accident scene is determining: A. whether spinal injury is present. B. the level of consciousness using the Glasgow coma scale. C. whether the airway is patent. D. whether hypotension is present.

whether spinal injury is present.