ML Quiz Ch 68

Which Glasgow Coma Scale score is indicative of a severe head injury? A. 7 B. 9 C. 11 D. 13

A

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? A. Widened pulse pressure B. Decreased respirations C. Decreased body temperature D. Increased pulse

A

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following are causes of secondary brain injury? Select all that apply. A. Seizures B. Hyperthermia C. Cerebral edema D. Ischemia E. Infection

A, B, C, D, E

Which are risk factors for spinal cord injury (SCI)? Select all that apply. A. Alcohol use B. Young age C. Caucasian ethnicity D. Female gender E. Drug abuse

A, B, E,

Which are possible long-term complications of spinal cord injury? Select all that apply. A. respiratory infection B. respiratory arrest C. autonomic dysreflexia D. areflexia

A, C

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 A. vomits. B. reports a headache. C. sleeps for short periods of time. D. reports generalized weakness.

A

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? A. Rebound hypotension B. Rebound hypertension C. Spinal shock D. Urinary tract infection

A

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? A. "I can apply powder under the liner to help with sweating." B. "If a pin becomes detached, I'll notify the surgeon." C. "I'll check under the liner for blisters and redness." D. "I will change the vest liner periodically."

A

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A. Herniation B. Paresthesia C. Paralysis D. Sciatic nerve pain

B

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? A. Keep accurate intake and output. B. Maintain a diet for the client that is high in protein, vitamins, and calories. C. Watch closely for signs of urinary tract infection. D. Avoid range of motion exercises for the client because of spasms.

B

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: A. Moderate TBI. B. Severe TBI. C. Brain death. D. Mild TBI.

B

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? A. Establishing an ambulation program using short leg braces B. Establishing an intermittent catheterization routine every 4 hours C. Preventing autonomic dysreflexia by preventing bowel impaction D. Managing spasticity with range-of-motion exercises and medications

B

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? A. The client with a concussion B. The client with a basilar fracture C. The client with an open head injury D. The client with a coup injury

B

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? A. Dressing or grooming self-care deficit B. Impaired verbal communication C. Risk for injury D. Disturbed sensory perception (visual)

C

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A. To prevent secondary brain injury B. To increase cerebral perfusion pressure C. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord D. So that the patient will not have a respiratory arrest

C

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 A. Falls B. Sports-related injuries C. Motor vehicle crashes D. Acts of violence

C

Which are characteristics of autonomic dysreflexia? A. severe hypotension, slow heart rate, anxiety, dry skin B. severe hypotension, tachycardia, nausea, flushed skin C. severe hypertension, slow heart rate, pounding headache, sweating D. severe hypertension, tachycardia, blurred vision, dry skin

C

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? A. Slight headache B. Runny nose C. Rapid heart rate D. Sweating

D

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply. A. Male gender B. Low-income community C. Older adult D. Young age E. Substance abuse

A. D. E

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? A. Evaluation for signs and symptoms of increased intracranial pressure (ICP) B. Lung auscultation and measurement of vital capacity and tidal volume C. Evaluation of pain and discomfort D. Evaluation of nutritional status and metabolic state

B

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? A. Cast B. Traction with weights and pulleys C. Cervical collar D. Turning frame

B

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? A. Paraplegia B. Spinal shock C. Cardiogenic shock D. Tetraplegia

B

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? A. Urinary output increase from 40 to 55 mL/hr B. Temperature increase from 98.0°F to 99.6°F C. Pulse oximetry decrease from 99% to 97% room air D. Heart rate decrease from 100 to 90 bpm

B

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? A. It results from initial damage to the brain from the traumatic event. B. It results from inadequate delivery of nutrients and oxygen to the cells. C. It refers to the difficulties suffered by the client and family related to the changes in the client. D. It refers to the permanent deficits seen after the rehabilitation process.

B

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A. Placing the client in Trendelenburg's position B. Monitoring the patency of an indwelling urinary catheter C. Administering zolpidem tartrate (Ambien) D. Assessing laboratory test results as ordered

B

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 differentiates the two disorders? A. The second cervical vertebrae B. The seventh thoracic vertebrae C. The first thoracic vertebrae D. The first lumbar vertebrae

C

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? A. contusion B. laceration C. concussion D. skull fracture

C

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? A. 12 to 24 hours B. 48 to 72 hours C. 18 to 36 hours D. 6 to 8 hours

C

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? A. Paraplegia B. Tetraplegia C. Autonomic dysreflexia D. Areflexia

C

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A. Disturbed thought processes related to brain injury B. Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction C. Ineffective cerebral tissue perfusion related to increased intracranial pressure D. Ineffective airway clearance related to brain injury

D

A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention? A. provide a change of scenery B. passive exercise C. maintain psychological well-being D. maintain sufficient integument capillary pressure

D

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A. Paralysis B. Sciatic nerve pain C. Herniation D. Paresthesia

D

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? A. Spinal shock B. Thrombophlebitis C. Orthostatic hypotension D. Autonomic dysreflexia

D

A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Positive Babinski's reflex along with spastic extremities B. Spasticity of all four extremities C. Hyperreflexia along with spastic extremities D. Absence of reflexes along with flaccid extremities

D

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? A. Depressed B. Comminuted C. Simple D. Basilar

D

At which of the following spinal cord injury levels does the patient have full head and neck control? A. C2 B. C3 C. C4 D. C5

D

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as A. least responsive. B. most responsive. C. minimally responsive. D. coma.

D

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A. Extreme thirst B. Intake and output C. Nutritional status D. Body temperature

D

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? A. Flaccid B. Decorticate C. Normal D. Decerebrate

D

Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Intracerebral hemorrhage B. Epidural hematoma C. Extradural hematoma D. Subdural hematoma

D

Which of the following is not a manifestation of Cushing's Triad? A. Hypertension B. Bradypnea C. Bradycardia D. Tachycardia

D