NUR 222 - Ch 45 - PrepU
Which of the following intracranial pressure (ICP) values would cause the nurse to contact the health care provider?
21 (p. 1190)
Which Glasgow Coma Scale score is indicative of a severe head injury?
7 (p. 1190)
A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?
Assess for a halo sign
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
vomits. (p. 1195)
Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical.
180 mg/dL (p. 1194)
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?
A small amount of yellow drainage at the left pin insertion site (p. 1186)
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities (p. 1204)
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*?
Autonomic dysreflexia (pp. 1205-1206)
A halo sign is indicative of which of the following complication of brain injury?
Cerebrospinal fluid (CSF) leak (p. 1186)
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Change in level of consciousness (LOC) (p. 1194)
Which of the following is the earliest sign of increasing intracranial pressure {ICP}?
Change in level of consciousness (LOC) (p. 1194)
The nurse is offering suggestions regarding reproductive options to a husband and para-plegic wife. Which option is most helpful?
Conception is not impaired; the birth process is determined with the physician.
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?
Decerebrate (p. 1188)
A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following?
Decerebrate positioning implying severe dysfunction and brain pathology (p. 1188, 1193)
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?
Ecchymosis over the mastoid
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.
Eye opening; Verbal response; Motor response (p. 1192)
Which of the following advice should the nurse give a client with impaired physical mobility to prevent maceration and decrease the potential for bacterial growth?
Keep the skin clean and dry. (p. 1199)
The most important nursing priority of treatment for a patient with an altered LOC is to:
Maintain a clear airway to ensure adequate ventilation. (p. 1192)
Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?
Mannitol (p. 1194, 1197)
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
Neurologic examination (p. 1190)
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?
Paresthesia
A patient with a spinal cord injury is complaining of pleuritic chest pain, shortness of breath, and is very anxious. These manifestations would most likely correlate with which complication?
Pulmonary embolism (PE) (p. 1205)
A client has sustained a *traumatic brain injury* with involvement of the *hypothalamus*. The health care team is concerned about the complication of *diabetes insipidus*. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?
Record intake and output. (p. 1197)
Which of the following are the immediate complications of spinal cord injury?
Respiratory arrest; Spinal shock
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?
Risk for injury (p. 1186)
A nurse on the neurological unit is caring for a client with a basilar skull fracture. Which high-risk nursing diagnosis is appropriate for this client?
Risk for meningeal infection (p. 1186)
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma (p. 1189)
Which of the following is not a manifestation of Cushing's Triad?
Tachycardia (p. 1191)
Patient admitted to hospital after sustaining a closed head injury in a skiing accident. Physician ordered neurologic assessments every 2 hours. Patient's neurologic assessments unchanged since admission. Patient is complaining of a headache. Which intervention by the nurse is best?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. (p. 1187)
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?
Burr holes (p. 1189)
