Neuro Nurselabs
A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). 1. Raise the head of the bed. 2. Contact the physician. 3. Administer an antihypertensive medication. 4. Check for bladder distention. 5. Loosen tight clothing on the client.
1. Raise the head of the bed. - Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and remove the noxious stimulus. 2. Loosen tight clothing on the client. 3. Check for bladder distention. - If the client has a foley catheter, the nurse should check for kinks in the tubing. 4. Contact the physician. - The physician is contacted especially if these actions do not relieve the signs and symptoms 5. Administer an antihypertensive medication. - Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal D. Significant; the client has alveolar hypoventilation.
A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. A subdural hematoma forms because of an accumulation of blood under the dura mater, one of the protective layers to the brain tissue under the calvarium.
In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? A. Keeping the client flat on one side or the other. B. Elevating the head of the bed to 30 degrees. C. Logrolling or turning as a unit when turning. D. Keeping the head in a neutral position.
B. Elevating the head of the bed to 30 degrees. Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.
Autonomic Dysreflexia
Autonomic dysreflexia is an abnormal, overreaction of the involuntary (autonomic) nervous system to stimulation. This reaction may include: - Change in heart rate. - Excessive sweating. - High blood pressure.
A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? A. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. B. Administer phenytoin (Dilantin) 200 mg PO daily. C. Teach the patient about the need for good oral hygiene. D. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.
B. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize.
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? A. Count the rate to be sure the ventilations are deep enough to be sufficient. B. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. C. Call the physician to adjust the ventilator settings. D. Check deep tendon reflexes to determine the best motor response.
B. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease.
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed. B. Check the fluid for dextrose with a dipstick. C. Suction the nose to maintain airway patency. D. Insert nasal and ear packing with sterile gauze.
B. Check the fluid for dextrose with a dipstick. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of CSF lost in a leak is very variable, ranging from insignificant to very substantial amounts.
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? A. "Watch him for a keyhole pupil the next 24 hours." B. "Expect profuse vomiting for 24 hours after the injury." C. "Wake him every hour and assess his orientation to person, time, and place." D. "Notify the physician immediately if he has a headache."
C. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are frequently assessed for 24 hours. Orient the patient to surroundings, staff, necessary activities as needed. Present reality concisely and briefly. Avoid challenging illogical thinking—defensive reactions may result. Increased orientation ensures greater degree of safety for the patient.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury. B. A client with a herniated nucleus pulposus. C. A client with a high cervical spine injury. D. A client with a stroke.
C. A client with a high cervical spine injury. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia. The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the greater the severity of the cardiovascular dysfunction. The severity and frequency of autonomic dysreflexia episodes are also associated with the completeness of the spinal cord injury.
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? A. Extent of intracranial bleeding. B. Sites of brain injury. C. Activity of the brain. D. Percent of functional brain tissue.
C. Activity of the brain. An EEG measures the electrical activity of the brain. An electroencephalogram (EEG) is an essential tool that studies the brain's electrical activity. It is primarily used to assess seizures and conditions that may mimic seizures. It is also useful to classify seizure types, assess comatose patients in the intensive care unit, and evaluate encephalopathies, among other indications.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury
C. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position.
D. Put the client in the high-Fowler's position. Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli.
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? A. "Clean the meatus from back to front." B. "Measure the quantity of urine." C. "Gently rotate the catheter during removal." D. "Clean the meatus with soap and water."
D. "Clean the meatus with soap and water." Intermittent (straight) catheterization may be performed chronically with a clean technique, using soap and water to clean the urinary meatus. Cleanse the perineal area and keep dry. Provide catheter care as appropriate. Decreases risk of skin irritation or breakdown and development of ascending infection.
Which of the following describes decerebrate posturing? A. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers. B. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet. C. Supination of arms, dorsiflexion of feet. D. Back arched; rigid extension of all four extremities.
D. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by the arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet.
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.
D. Raise the head of the bed immediately to 90 degrees. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing tetraplegic in sitting position automatically lowers BP.
A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia
D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia. Injuries above C5 may also cause respiratory compromise due to loss of innervation of the diaphragm.
The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: A. desmopressin (DDAVP, Stimate) B. Dexamethasone (Decadron) B. Dexamethasone (Decadron) C. ethacrynic acid (Edecrin) D. mannitol (Osmitrol)
A. Desmopressin (DDAVP, stimate) A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Desmopressin administration can be utilized to distinguish between central vs. nephrogenic diabetes insipidus, with a positive response noted in central diabetes insipidus, meaning the kidneys respond appropriately to desmopressin with the expected concentration of the urine and increased reabsorption of fluids, resulting in eutonic urine.
Which neurotransmitter is responsible for many of the functions of the frontal lobe? A. Dopamine B. GABA C. Histamine D. Norepinephrine
A. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia. Dopamine receptors play an essential role in daily life functions. This hormone and its receptors affect movement, emotions and the reward system in the brain.
The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. A. Elevate the HOB to 90 degrees. B. Loosen constrictive clothing. C. Use a fan to reduce diaphoresis. D. Assess for bladder distention and bowel impaction. E. Administer antihypertensive medication. F. Place the client in a supine position with legs elevated.
A. Elevate the HOB to 90 degrees. B. Loosen constrictive clothing. D. Assess for bladder distention and bowel impaction. E. Administer antihypertensive medication. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A. Evaluate urine specific gravity. B. Anticipate treatment for renal failure. C. Provide emollients to the skin to prevent breakdown. D. Slow down the IV fluids and notify the physician.
A. Evaluate urine specific gravity. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration.
A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A. Laceration of the middle meningeal artery. B. Rupture of the carotid artery. C. Thromboembolism from a carotid artery. D. Venous bleeding from the arachnoid space.
A. Laceration of the middle meningeal artery. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Most epidural hematomas result from arterial bleeding from a branch of the middle meningeal artery. The anterior meningeal artery or dural arteriovenous (AV) fistula at the vertex may be involved.
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? A. Quadriplegia with gross arm movement and diaphragmatic breathing. B. Quadriplegia and loss of respiratory function. C. Paraplegia with intercostal muscle loss. D. Loss of bowel and bladder control.
A. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Cervical spine injuries, although uncommon, can result in significant and long-term disability. The cervical spine encompasses seven vertebrae and serves as a protection to the spinal cord. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion.
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A. Reposition the client to avoid neck flexion. B. Administer 1 g Mannitol IV as ordered. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as ordered.
A. Reposition the client to avoid neck flexion. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. Elevate the head of the bed to greater than 30 degrees. Keep the neck midline to facilitate venous drainage from the head. Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure.
Which of the following respiratory patterns indicate increasing ICP in the brain stem? A. Slow, irregular respirations B. Rapid, shallow respirations C. Asymmetric chest expansion D. Nasal flaring
A. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Raised intracranial pressure can overcome perfusion pressure causing further anoxia and injury leading to brain death and/or herniation. Although hyperventilation can lower PaCO2, causing vasoconstriction and reduce swelling/ICP, it should be avoided.
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? A. Unequal pupil size B. Decreasing systolic blood pressure C. Tachycardia D. Decreasing body temperature
A. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma.
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence
B. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Spinal shock is a result of severe spinal cord injury. It usually requires high-impact, direct trauma that leads to spinal cord injury and spinal shock. The initial encounter with a patient that has spinal shock is usually under a trauma scenario.
A client has been pronounced brain dead. Which findings would the nurse assess? Select all that apply. A. Decerebrate posturing B. Dilated nonreactive pupils C. Deep tendon reflexes D. Absent corneal reflex
B. Dilated nonreactive pupils C. Deep tendon reflexes D. Absent corneal reflex A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria
B. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. In the occurrence of a leak in the postoperative period, the patient is advised bed rest, and a lumbar drain is placed. If the leak does not improve in 24 hours, exploration and closure of the defect are to be done. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications.
The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: A. A flattened abdomen. B. Hematest positive nasogastric tube drainage. C. Hyperactive bowel sounds. D. A history of diarrhea.
B. Hematest positive nasogastric tube drainage. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. Gastrointestinal dysfunction including constipation, straining, diarrhea, distention, abdominal pain, incontinence, rectal bleeding, hemorrhoids, and autonomic dysreflexia during bowel movements occur in 27% to 62% of individuals with a spinal cord injury. During the acute stage of spinal cord injury there is an increased risk of gastrointestinal complications within the first few days post injury, including gastrointestinal hemorrhage, perforation, and paralytic ileus, while neurogenic bowel, affecting almost half of those with a spinal cord injury (46.9%) is a major problem long term both in terms of physical and psychological well being.
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock
B. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion.
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program. B. Limiting bladder catheterization to once every 12 hours. C. Keeping the linen wrinkle-free under the client. D. Preventing unnecessary pressure on the lower limbs.
B. Limiting bladder catheterization to once every 12 hours. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Eliminate causative stimulus as able such as bladder, bowel, skin pressure (including loosening tight leg bands or clothing, removing abdominal binder or elastic stockings); temperature extremes.
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. B. Rapid Dilantin administration can cause cardiac arrhythmias. C. Dilantin should be mixed in dextrose in water before administration. D. Dilantin should be administered through an IV catheter in the client's hand.
B. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. The drug is slowly administered intravenously directly into a large central or peripheral vein through an IV catheter less than 20 gauge, not exceeding a rate of 50 mg/minute.
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.
B. Schedule intermittent catheterization every 2 to 4 hours. Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé's maneuver).
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together.
B. To immobilize the cervical spine. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished. There are several uses for GWT, including the treatment of cervical spine fractures, patient positioning inside the operating room, and skeletal traction during spinal deformity surgery. Aside from GWT, different apparatuses have been utilized for skeletal traction, including Crutchfield's caliper, Cone's caliper, Blackburn's caliper, and halo traction.
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? A. Place her in a jacket restraint. B. Wrap her hands in soft "mitten" restraints. C. Tuck her arms and hands under the draw sheet. D. Apply a wrist restraint to each arm.
B. Wrap her hands in soft "mitten" restraints. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Communicate therapeutically with the patient and answer questions calmly and honestly. Promotes a calm and supportive environment.
When discharging a client from the ER after head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval?
C. An interval when the client is oriented but then becomes somnolent. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. The lucid interval following head trauma and unconsciousness is described classically in epidural hematomas. The historic emphasis placed on the lucid interval in cases of extradural hematoma has made this one of the best-remembered signs of the syndrome. Initial unconsciousness is thought to be due to the concussive effect of the blow to the head. The lucid period is the time required for the clot to grow to proportions great enough to produce compression of the brain.
A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? A. By inserting a nasopharyngeal airway. B. By inserting an oropharyngeal airway. C. By performing a jaw thrust maneuver. D. By performing the head-tilt, chin-lift maneuver.
C. By performing a jaw thrust maneuver. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Patients with high cervical injury and impaired gag and cough reflexes require assistance in preventing aspiration and maintaining patient airway. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury. Tilting the head or otherwise moving the neck is contraindicated in a patient with a possible cervical spine injury, but maintaining an airway and ventilation is a greater priority. In the setting of a possible cervical spine injury, the jaw-thrust maneuver, in which the neck is held in a neutral position, is preferred over the head tilt-chin lift maneuver.
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? A. Give the client a warming blanket. B. Administer low-dose barbiturate. C. Encourage the client to hyperventilate. D. Restrict fluids.
C. Encourage the client to hyperventilate. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. Hyperventilation causes hypocapnia, which causes vasoconstriction, thus decreasing cerebral blood flow. Hyperventilation to moderate levels (PaCO2 = 25-35) is generally considered a short-term temporizing measure to decrease ICP. Extreme hyperventilation (PaCO2 <25mmHg) should be avoided.
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? A. Subdural hematoma B. Subarachnoid hemorrhage C. Epidural hematoma D. Contusion
C. Epidural hematoma An epidural hematoma occurs when blood collects between the skull and the dura mater. An epidural hematoma (EDH) is an extra-axial collection of blood within the potential space between the outer layer of the dura mater and the inner table of the skull. It is confined by the lateral sutures (especially the coronal sutures) where the dura inserts. It is a life-threatening condition, which may require immediate intervention and can be associated with significant morbidity and mortality if left untreated. Rapid diagnosis and evacuation are important for a good outcome.
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open the airway with the head-tilt-chin-lift maneuver.
C. Immobilize the client's head and neck. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The management of patients with head trauma should always consider C-spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape.
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? A. Positive reflexes B. Hyperreflexia C. Inability to elicit a Babinski's reflex. D. Reflex emptying of the bladder.
C. Inability to elicit a Babinski's reflex. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex. It is more appropriate to use the trauma activation code announced when a patient with spinal shock arrives at the emergency department, that way the trauma team can complete a full workup for the patient. The full spinal examination should include motor, sensory reflexes including bulbocavernosus reflex and anal wink reflex.
A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. acetazolamide (Diamox) B. furosemide (Lasix) C. methylprednisolone (Solu-Medrol) D. sodium bicarbonate
C. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate-acting, synthetic glucocorticoids used mainly as anti-inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti-inflammatory properties relative to hydrocortisone (cortisol), with minimal mineralocorticoid activities compared to the latter.
The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? A. Monitoring vital signs before and during position changes. B. Using vasopressor medications as prescribed. C. Moving the client quickly as one unit. D. Applying Teds or compression stockings.
C. Moving the client quickly as one unit. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Immobilize the patient. A sandbag and tape are not sufficient. Spinal immobilization in patients with penetrating trauma is not recommended. Patients with spinal cord injury need to be evaluated in a timely fashion to minimize secondary injuries. Preferably, these patients should be evaluated at level one trauma centers due to the extent of injuries.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis
C. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. - Autonomic dysreflexia occurs after neurogenic shock abates.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism
C. Neurogenic shock - Neurogenic shock is a condition in which you have trouble keeping your heart rate, blood pressure and temperature stable because of damage to your nervous system after a spinal cord injury. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation.
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? A. Widening pulse pressure B. Decrease in the pulse rate C. Dilated, fixed pupil D. Decrease in LOC
D. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Clinical suspicion for intracranial hypertension should be raised if a patient presents with the following signs and symptoms: headaches, vomiting, and altered mental status varying from drowsiness to coma. - Dilated, fixed pupils occur later if the increased ICP is not treated. A funduscopic exam can reveal papilledema which is a tell-tale sign of raised ICP as the cerebrospinal fluid is in continuity with the fluid around the optic nerve.
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: A. Skull fracture B. Concussion C. Subdural hematoma D. Epidural hematoma
D. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly. Often, the bleeding is undetected initially, discovered as a chronic subdural hematoma. When there is a sufficient accumulation of blood to occupy a large intracranial space, the brain midline shifts toward the opposite side, encroaching on the brain structures against the inner surface of the calvarium after decreasing the volume of the lateral third and fourth ventricles. As the intracranial space becomes limited, the volumetric forces push the uncal portion of the temporal lobe toward the foramen magnum causing herniation of the brain.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli
D. Noxious stimuli Noxious stimuli, such a s a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia. Dysregulation of the autonomic nervous system leads to an uncoordinated autonomic response that may result in a potentially life-threatening hypertensive episode when there is a noxious stimulus below the level of the spinal cord injury. In about 85% of cases, this stimulus is from a urological source such as a UTI, a distended bladder, or a clogged Foley catheter. - Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Spinal cord injuries below T10 rarely result in autonomic dysreflexia because the splanchnic innervation remains intact and allows for compensatory parasympathetic dilation of the splanchnic vascular bed. The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the greater the severity of the cardiovascular dysfunction.
The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: A. Keeping the client on a stretcher. B. Logrolling the client on a firm mattress. C. Logrolling the client on a soft mattress. D. Placing the client on a Stryker frame.
D. Placing the client on a Stryker frame. Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? A. Absent corneal reflex. B. Decerebrate posturing. C. Movement of only the right or left half of the body. D. The need for mechanical ventilation.
D. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. C3 to C4 contribute to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing.
After a hypophysectomy, vasopressin is given IM for which of the following reasons? A. To treat growth failure. B. To prevent syndrome of inappropriate antidiuretic hormone (SIADH). C. To reduce cerebral edema and lower intracranial pressure. D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy or removal of the pituitary gland, the body can't synthesize ADH. Initial management includes oral fluid replacement. However, in the event of unresolved DI, therapy is stepped up, ranging from fluid replacement with 5% dextrose to the administration of synthetic ADH analog, desmopressin. Intranasal desmopressin is the drug of choice for chronic cases of DI.
