MSN 377: Ch 68 Workbook Questions

A

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in the situation? A. epidural hematoma B. acute subdural hematoma C. chronic subdural hematoma D. grade 1 concussion

A

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? A. irrigates the wound to remove debris B. administers an oral analgesic for pain C. administers acetaminophen (Tylenol) for headache D. shaves the hair around the wound

C

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? A. voice or sip-n-puff controlled electric wheelchair B. electric or modified manual wheelchair, needs transfer assistance C. cane D. the patient will be able to ambulate independently

C

A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure? A. nifedipine (Procardia) sublingual B. furosemide (Lasix) IV administered rapidly C. hydralazine hydrochloride (Apresoline) IV administered slowly D. Bumex rapid bolus IV

D

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? A. Lorazepam (Ativan) B. Midazolam (Versed) C. Phenobarbital D. Propofol (Diprivan)

B

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

D

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? A. occipital skull fracture B. temporal skull fracture C. frontal skull fracture D. basilar skull fracture

C

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? A. hypophysectomy B. application of Halo traction C. Burr holes D. insertion of Crutchfield tongs

A, B, C, D

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? (Select all that apply.) A. making nurse assessments B. setting priorities for nursing interventions C. anticipating needs and complications D. initiating rehabilitation E. ensuring that the patient regains full brain function

B

While stopped at a stop sign, a patient 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 the injury peak? A. 6 to 8 hours b. 18 to 36 hours C. 12 to 24 hours D. 48 to 72 hours

A, B, 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. young age B. male gender C. older adult D. substance abuse E. low-income community

C

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? A. grade 1 concussion B. grade 2 concussion C. grade 3 concussion D. grade 4 concussion

A

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? A. place the patient in a sitting position B. call the physician C. assess the patient for a full bladder D. assess the patient for a fecal impaction

C

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? A. an epidural hematoma B. an extradural hematoma C. an intracerebral hematoma D. a subdural hematoma

B

A patient was body surfing int he ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit form the application of the halo device? A. it is the only device that can be applied for stabilization of a spinal fracture B. it allows for stabilization of the cervical spine along with early ambulation C. it is less bulky and traumatizing for the patient to use D. the patient can remove it as needed