Neuro/Spinal Cord Injury

The nurse is caring for the client with increased intracranial pressure. The nurse would note which trend in vital signs if the intracranial pressure is rising? 1. Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2. Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3. Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4. Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Irregular respirations may also occur

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1. Hyperreflexia 2. Positive reflexes 3. Flaccid paralysis 4. Reflex emptying of the bladder

3 Resolution of spinal shock is occurring when there is return of reflexes, a state of hyperreflexia rather than flaccidity and reflex of emptying the bladder

Which respiratory pattern indicates increased ICP pressure in the brain stem 1. Slow, irregular respirations 2. rapid, shallow respirations 3. asymmetric chest excursion 4. nasal flaring

1 Neural control of respiration takes place in the brain stem. deterioration and pressure produce slow and irregular respirations. rapid and shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia

The nurse is caring for the client with a SCI at the level of the sixth cervical vertebra. Which findings support the nurse's conclusion that the client may be experiencing autonomic dysreflexia? Select all that apply 1. Blurred vision 2. BP 198/102 3. HR 150 4. Extreme headache 5. Sweaty face and arms

1,2,4,5 Hypertension occurs because of overstimulation of the SNS. Blurred vision and extreme headache occur from the hypertension. Sweating results from the sympathetic stimulation above the level of injury.

A client is at risk fro increased intracranial pressure. Which finding is the priority for the nurse to monitor? 1. unequal pupil size 2. decreasing systolic blood pressure 3. tachycardia 4. decreasing body temperature

1 Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. it increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage

The client has a sustained increase ICP of 20 mm Hg Which client position would be most appropriate? 1. The head of the bed elevated 15 to 20 degrees 2. trendelenburg's psoition 3. left Sim's position 4. The head elevated on two pillows

1 The clients ICP is elevated, and the cleint should be positioned to avoid extreme neck flexion or extension. the head of the bed is usually elevated 15-20 degrees to drain the venous sinuses and thus decrease the ICP. Trendelenburg position places the clients head lower than the body, which would increase ICP. Sims position(side lying) and elevating the head on two pillows may extend or flex the neck, which increases ICP

The nurse has completed discharge instructions for a client with application of a halo device. Which statement indicates that the client needs further clarification of the instructions? 1. "I will use a straw for drinking" 2. "I will drive only during the daytime" 3. "I will be careful because the device alter balance" 4. "I will wash the skin daily under the lamb's wool liner of the vest"

2 The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powders or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all because the device impairs range of vision.

A client with contusion has been admitted for observation following a MVA when he was driving his pregnant wife to the hospital. The next morning, instead of asking about his wife and baby, he asked to see the football game on television that he thinks is starting in 5 minutes. He is agitated because the nurse will not turn on the television. What should the nurse do next select all that apply? 1. Find a television so the client can view the football game 2. Determine if the clients pupils are equal and react to light 3. Ask the client if he has a headache 4. Arrange for the client to be with his wife and baby 5. Administer a sedative

2,3 The nurse should determine if the client's pupils are equal and react to light, and ask the client if he has a headache. Confusion, agitation, and restlessness are subtle clients manifestations of increased ICP. At this time it is not appropriate for the nurse to find a television or arrange for the client to see his wife and baby. Administering a sedative at this time will obscure assessment of increase ICP

The nurse has established a goal to maintain intracranial pressure within the normal range for a client who had a craniotomy 12 hours ago. What should the nurse do? Select all that apply 1. Encourage the client to cough to expectorate secretions 2. Elevate the head of the bed 15 to 20 degrees 3. Contact the healthcare provider if ICP is >15mm hg 4. Monitor neurological status using the Glasgow coma scale. 5. Stimulate the client with active range of motion exercises

2,3,4 The nurse should maintain ICP by elevating the head of the bed 15- 20 degrees and monitoring neurological status. An ICP >15mmhg with 20-25 mmhg as upper limits of normal indicated increased ICP, and the nurse should notify to the HCP. Coughing and range of motion exercises will increase ICP and should be avoided in the early postoperative stages.

The nurse learns in report that the client admitted with a vertebral fracture has a halo external fixation device in place. Which intervention should the nurse plan? 1. Ensure the traction weight hangs freely 2. Remove the best from the device at bedtime 3. Cleanse sites where the pins enter the skull 4. Screw the pins in the skull daily to tighten

3 A halo external fixation device is a static device that consists of a "halo" that is screwed into the skull by four pins. It is attached to a best that the client wears. The device provides immobilization and stability to the spinal cord while healing occurs with or without surgical intervention. Care includes inspection and cleansing of the pins sites.

Spinal precautions are ordered for the client who sustained a neck injury during an MVA. The client has yet to be cleared that there is no cervical fracture. Which action is the nurse's priority when receiving the client in the ED? 1. Assessing the client using the GSC scale 2. Assessing the level of sensation in the client's extremities 3. Checkin that the cervical collar was correctly placed by EMS 4. Applying antiembolism hose to the client's lower extremities

3 Maintaining the correct placement of the cervical collar will keep the client's head and neck in a neutral position and prevent further injury if a spinal fracture or SCI is present. Because ensuring that the cervical collar will prevent further injury, this is the priority.

Which activity should the nurse encourage the client to avoid when there is a risk for increased ICP 1. deep breathing 2. turning 3. coughing 4. passive range of motion exercises

3 Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. deep breathing can be continued. Turing and passive range of motion can be continued with care not to extend or flex the neck

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. using the Glasgow coma scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. what should the nurse do? 1. Attempt to arouse the client 2. Reposition the client with the extremities in normal alignment 3. Chart the client's level of consciousness as coma 4. Notify the healthcare provider

3. The client has a score of 6. A score <7 is indicative of coma. While the nurse should continue to speak to the client, at this time the client will not be bale to be aroused. The nurse should continue to provide skin care and appropriate alignment, but the client will continue to have a motor response of limb extension. It is not necessary to notify the HCP as this assessment does not represent a significant change in neurological status

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1. Blowing the nose 2. Isometric exercises 3. Coughing vigorously 4. Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis which prevents intrathoracic pressure from rising

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1. Fluid is clear and tests negative for glucose 2. Fluid is grossly bloody in appearance and has a pH of 6 3. Fluid clumps together on the dressing and has a pH of 7 4. Fluid separates into concentric rings and tests positive for glucose

4 Leakage of cerebrospinal fluid from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose

A client has delirium following a head injury. The client is disoriented and agitated. In which order from first to last should the nurse initiate care for this client? 1. Request a prescription for haloperidol 2. Maintain a quiet environment 3. Assure the clients safety 4. Approach the client using short sentences

4,3,2,1 The first step in providing care for a client with delirium is to approach the client calmly, introduce oneself, and use short questions when explaining the care given. The nurse should also assure the clients safety by protecting the clients from injury. Maintaining a quiet and calm environment by removing extraneous noises will prevent over stimulation. Pharmacologic intervention is used only when other plans fro care are not effective. When the underlying problems related to the head injury are resolve, the delirium likely will improve

The nurse is monitoring a client with increased ICP. What indicators are the MOST critical for the nurse to monitor? Select all the apply. 1. Systolic BP 2. Urine output 3. Breath sounds 4. Cerebral perfusion pressure 5. Level of pain

1, 4 The nurse must monitor the systolic and diastolic BP to obtain the mean arterial pressure, which represents the pressure needed for each cardiac cycle to perfuse the brain. The nurse must also monitor the cerebral perfusion pressure, which is obtained from the ICP and the MAP. The nurse should also monitor urine output, respirations and pain; however crucial measurements needed to maintian CPP are ICP and MAP. When ICP equals MAP, there is no CPP

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. the nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply 1. Keeping the linens wrinkle-free under the client 2. Preventing unnecessary pressure on the lower limbs 3. Limiting bladder catheterization to once every 12 hours 4. Turning and repositioning the client at least every 2 hours 5. Ensuring that the client has a bowel movement at least once a week

1,2,4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4-6 hours as every 12 hours is too infrequent. Urinary caths should be checked frequently for kinks in tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is too infrequent. Other causes include stimulation of the skin from tactile, thermal or painful stimuli. The nurse administers care to minimize risk in these areas

The nurse is assessing the client with a tentative diagnosis of meningitis. Which findings should the nurse associate with meningitis? Select all that apply 1. Nuchal rigidity 2. Severe headache 3. Pill-rolling tremor 4. Photophobia 5. Lethargy

1,2,4,5 Irritation of the meninges causes nuchal rigidity (stiff neck). Irritation of the meninges causes severe headache and photophobia (light irritates the eyes). Lethargy indicates a decreased level of consciousness which is associated with meningitis. Pin rolling tremors are not associated with meningitis

The female client with an incomplete T6 spinal cord transection asks the nurse for sexual health advice and the possibility of ever conceiving. Which statement by the nurse will be helpful to the client. Select all that apply 1. "You need to continue to use contraceptives if you do not wish to have children" 2. "Unfortunately your injury prevents you from being able to conceive" 3. "Because feeling is affected, it is not likely that you will be able to deliver a baby" 4. "Sexual intercourse is generally prohibited because it can worsen your condition" 5. "You can engage in sexual intimacy but you may not be able to feel an orgasm"

1,5 Although the client has an incomplete T6 SCI, the woman is still capable of becoming pregnant. She can still deliver a baby and sexual intercourse is allowed but the client may not be able to feel an orgasm.

An unconscious person with multiple injuries to the head and neck arrives in the emergency department. What should the nurse do first? 1. establish an airway 2. determine the identity of the client 3. Stop bleeding form open wounds 4. Check for a neck fracture

1. Unless the client has a patent airway, other care measures will be futile. Determining the clients identity, blood loss, stopping bleeding form open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established

The nurse assesses the client who was injured in a diving accident 2 hours earlier. The client is breathing independently but has no movement or muscle tone from below the area of injury. A CT scan reveals a fracture of the C4 cervical vertebra. The nurse should plan interventions for which problem? 1. Complete spinal cord transection 2. Spinal shock 3. An upper motor neuron injury 4. Quadriplegia

2 The client is experiencing spinal shock that manifests within a few hours after injury. Hypotension, flaccid paralysis and absence of muscle contractions occur. Spinal shock lasts 7-20 days and the SCI cannot be classified accurately until spinal shock resolves.

The nurse is assessing a client with increasing ICP. the nurse should notify the healthcare provider about which early change in the client's condition 1. widening pulse pressure 2. decrease in the pulse rate 3. dilated fixed pupils 4. decrease in level of consciousness

4 A decrease in the clients LOC is an early indicator of deterioration of the clients neurologic status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure,decrease in the pulse rate, and dilated fixed pupils occur later if the increased ICP is not treated

What should the nurses do first when a client with a head injury begins to have clear drainage from the nose 1. compress the nares 2. tilt the head back 3. collect the drainage 4. Administer an antihistamine for postnasal drip

3 The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid. the nurse should not give the client tissues because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. it is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. it is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip

A client who has had a serious head injury with increased ICP is to be discharged to a rehab facility. which outcome of rehabilitation would be appropriate for the client? The client will... 1. exhibit no further episodes of short term memory loss 2. be able to return to his construction job in 3 weeks 3. actively participate in the rehabilitation process as appropriate 4. be emotionally stable and display preinjury personality traits

3 recovery from a serious head injury is a long term process that may continue for months or years. depending on the extent of the injury, clients who transferred to rehab facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. The client would be expected to participate in the rehab efforts to the extend he is capable. Family members and significant others will need long term support to help them cope with the changes that have occurred in the client

The nurse's client with a T2 SCI is dysreflexic and has a BP of 170/90. Place the nurse's interventions in the order that these should be performed. 1. Lower the end of the bed so the feet are dependent 2. Remove elastic stocking and other constricting devices: assess below the level of injury 3. Elevate HOB to 90 degrees 4. Inform the HCP of the incident, measures taken and client response 5. Perform digital removal of impacted stool (last BM found to be 10 days ago) 6. Administer PRN prescribed sublingual nifedipine for continued elevated BP 7. Retake the BP after being upright for 2-3 minutes

3,1,2,7,6,5,4 Elevate HOB first because it is a quick actin that may help lower the client's BP Lower the end of the bed will allow the feet to be lower than the head which will help decrease blood return and may help lower the BP Removing any constricting items below the level of injury can help because it is a stimuli for autonomic dysreflexia. The nurse can assess for other precipitating factors such as a full bladder, while removing constricted devices Retake the BP next because the HOB is elevated, the feet are lowered and constricted devices are removed which may have lowered the BP, if not, further interventions are needed. Administer a PRN med if the elevated BP persists to quickly lower the BP Perform digital removal of stool because this can cause a spike in BP and is a stimuli for autonomic dysreflexia Inform the HCP last because a PRN antihypertensive med was already prescribed and care of the client is the priority.