NUR 4770- Exam 1: PrepU Ch. 68 Management of Pts w/Neurologic Trauma
18. A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? "They prepare you to function in the absence of your leg function." "They help prevent the development of contractures." "They aid in restoring your skeletal integrity." "They help stabilize total body functioning."
"They help prevent the development of contractures." Explanation: Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.
16. The earliest sign of serious impairment of brain circulation related to increased ICP is: A change in consciousness. A bounding pulse. Hypertension. Bradycardia.
A change in consciousness. Explanation: The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.
6. 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? Flaccid Decerebrate Decorticate Normal
Decerebrate Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
59. Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Monro-Kellie hypothesis Herniation Autoregulation Cushing's response
Herniation Explanation: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
46. A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury
Ineffective airway clearance related to brain injury Explanation: Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.
34. 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? Irrigates the wound to remove debris Administers an oral analgesic for pain Shaves the hair around the wound Administers acetaminophen (Tylenol) for headache
Irrigates the wound to remove debris Explanation: Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.
1. The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has an elevated temperature. The client has ecchymosis in the periorbital region. The client has serous drainage from the nose. The client has cerebral spinal fluid (CSF) leaking from the ear.
The client has cerebral spinal fluid (CSF) leaking from the ear. Explanation: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.
39. Which are risk factors for spinal cord injury (SCI)? Select all that apply. Drug abuse Young age Female gender Alcohol use European American ethnicity
Young age Alcohol use Drug abuse Explanation: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.
11. Which Glasgow Coma Scale score is indicative of a severe head injury? 7 9 11 13
7 Explanation: A score between 3 and 8 is generally accepted as indicating a severe head injury.
49. The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?
80 Explanation: 20/15 × 60 = 80 mL/hr
31. 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 Disturbed sensory perception (visual) Impaired verbal communication Dressing or grooming self-care deficit
Risk for injury Explanation: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.
47. A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5
C5 Explanation: At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.
3. 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? Temporal skull fracture Frontal skull fracture Basilar skull fracture Occipital skull fracture
Basilar skull fracture Explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
38. When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature
Body temperature Explanation: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
19. Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? Pupil changes Seizures Change in level of consciousness (LOC) Restlessness
Change in level of consciousness (LOC) Explanation: The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.
9. 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? Assess for pupillary response frequently. Assess frequent vital signs. Reposition frequently. Record intake and output.
Record intake and output. Explanation: A record of intake and output is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. Excessive output will alert the nurse to possible fluid imbalance early in the process.
61. The Monro-Kellie hypothesis refers to which of the following? The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function Unresponsiveness to the environment The dynamic equilibrium of cranial contents
The dynamic equilibrium of cranial contents Explanation: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. Cushing's response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.
27. A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.
1.6 Explanation: (100 mg/125 mg) x 2 mL = 1.6 mL.
13. The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Drainage of cerebrospinal fluid from the ears Drainage of cerebrospinal fluid from the nose Bruising under the eyes Ecchymosis over the mastoid
Ecchymosis over the mastoid Explanation: With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.
5. The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate? Edema to the head with bruising of the mastoid process Edema to the head with a large scalp laceration Edema to the head and a blackened eye Edema to the head with fixed pupils
Edema to the head with bruising of the mastoid process Explanation: Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.
36. For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest To increase cerebral perfusion pressure Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
4. A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis? Ineffective breathing pattern Impaired physical mobility Dressing or grooming self-care deficit Disturbed sensory perception (tactile)
Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
32. The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Insertion of a nasogastric (NG) tube Urine testing for acetone Serum sodium concentration testing Out of bed to the chair three times a day
Insertion of a nasogastric (NG) tube Explanation: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.
48. The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? Maintain cerebral perfusion pressure from 50 to 70 mm Hg Restrain the client, as indicated Administer enemas, as needed Position the client in the supine position
Maintain cerebral perfusion pressure from 50 to 70 mm Hg Explanation: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
30. A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: preservation of a sense of touch below the level of the lesion. loss of the sensation of pain and temperature on the side opposite the injury. loss of motor power, pain, and temperature sensation below the level of the lesion. loss of motor power and sensation in the upper extremities.
loss of motor power and sensation in the upper extremities. Explanation: Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved.
37. Which are characteristics of autonomic dysreflexia? severe hypotension, tachycardia, nausea, flushed skin severe hypertension, tachycardia, blurred vision, dry skin severe hypertension, slow heart rate, pounding headache, sweating severe hypotension, slow heart rate, anxiety, dry skin
severe hypertension, slow heart rate, pounding headache, sweating Explanation: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
29. 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? "I'll check under the liner for blisters and redness." "I can apply powder under the liner to help with sweating." "If a pin becomes detached, I'll notify the surgeon." "I will change the vest liner periodically."
"I can apply powder under the liner to help with sweating." Explanation: Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.
50. 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? Cast Cervical collar Traction with weights and pulleys Turning frame
Traction with weights and pulleys Explanation: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
14. A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? It is the only device that can be applied for stabilization of a spinal fracture. It is less bulky and traumatizing for the patient to use. It allows for stabilization of the cervical spine along with early ambulation. The patient can remove it as needed.
It allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.
56. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Respiratory pattern Numbness and tingling Pulse and blood pressure Pain level
Pulse and blood pressure Explanation: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
45. 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? 6 to 8 hours 12 to 24 hours 18 to 36 hours 48 to 72 hours
18 to 36 hours Explanation: Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.
24. A client with quadriplegia is in spinal shock. What finding should the nurse expect? Spasticity of all four extremities Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities Hyperreflexia along with spastic extremities
Absence of reflexes along with flaccid extremities Explanation: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
8. The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation? An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's ear A bloodstain surrounded by a yellowish stain on the head dressing Escape of cerebrospinal fluid from the client's nose
An area of bruising over the mastoid bone Explanation: Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.
10. 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? Tetraplegia Areflexia Autonomic dysreflexia Paraplegia
Autonomic dysreflexia Explanation: Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
44. 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? Autonomic dysreflexia Spinal shock Orthostatic hypotension Thrombophlebitis
Autonomic dysreflexia Explanation: Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.
51. The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Concussion Autonomic dysreflexia Contusion Spinal shock
Autonomic dysreflexia Explanation: Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.
40. 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 this situation? Grade 1 concussion Acute subdural hematoma Chronic subdural hematoma Epidural hematoma
Epidural hematoma Explanation: Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.
35. 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 Muscle strength Verbal response Intelligence Motor response
Eye opening Verbal response Motor response Explanation: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.
33. A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Lower back pain Frequency of urination Fever and change in urine clarity Burning sensation on urination
Fever and change in urine clarity Explanation: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.
43. A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: Apnea Coma Glasgow Coma Scale of 6 Absence of brain stem reflexes
Glasgow Coma Scale of 6 Explanation: The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.
57. 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? Grade 2 concussion Grade 4 concussion Grade 1 concussion Grade 3 concussion
Grade 3 concussion Explanation: There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).
15. A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Have the client avoid physical exertion Emphasize complete bed rest Look for a halo sign Look for signs of increased intracranial pressure
Look for signs of increased intracranial pressure Explanation: The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.
41. Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? Continuous use of an indwelling catheter Avoidance of all lotions and lubricants Allowing the client to choose the position of comfort Meticulous cleanliness
Meticulous cleanliness Explanation: Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.
55. Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Monitoring the patency of an indwelling urinary catheter Assessing laboratory test results as ordered Placing the client in Trendelenburg's position.
Monitoring the patency of an indwelling urinary catheter Explanation: A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
26. 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? Herniation Sciatic nerve pain Paralysis Paresthesia
Paresthesia Explanation: When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
60. A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? Notify the physician. Place the client in a sitting position. Apply antiembolic stockings. Lay the client flat.
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
2. 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? Lorazepam (Ativan) Midazolam (Versed) Propofol (Diprivan) Phenobarbital
Propofol (Diprivan) Explanation: If the patient is very agitated, benzodiazepines are the most commonly used sedative agents and do not affect cerebral blood flow or ICP. Lorazepam (Ativan) and midazolam (Versed) are frequently used but have active metabolites that my cause prolonged sedation, making it difficult to conduct a neurologic assessment. Propofol ( Diprivan), on the other hand, a sedative-hypnotic agent that is supplied in an intralipid emulsion for intravenous (IV) use, is the sedative of choice. It is an ultra-short acting, rapid onset drug with elimination half-life of less than an hour. It has a major advantage of being titratable to its desired clinical effect but still provides the opportunity for an accurate neurologic assessment (Hickey, 2009).
42. Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Examine the rectum for a fecal mass. Examine the skin for any area of pressure or irritation. Raise the head of the bed and place the patient in a sitting position. Empty the bladder immediately.
Raise the head of the bed and place the patient in a sitting position. Explanation: The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
58. 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? Urinary tract infection Spinal shock Rebound hypertension Rebound hypotension
Rebound hypotension Explanation: When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.
12. 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: Severe TBI. Brain death. Mild TBI. Moderate TBI.
Severe TBI. Explanation: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
21. Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? Myoclonus Spasticity Akathisia Ataxia
Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.
17. Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
23. 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? Sweating Rapid heart rate Runny nose Slight headache
Sweating Explanation: Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.
53. Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? Hypertension Irregular respiration Tachycardia Widening pulse pressure
Tachycardia Explanation: Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.
20. A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? Assess for pupillary response frequently. Assess vital signs frequently. Take daily weights. Reposition the client frequently.
Take daily weights. Explanation: A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.
52. The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The client prefers to rest in the semi-Fowler's position. The client has periorbital edema and ecchymosis. The client's level of consciousness has improved.
The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. Explanation: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.
22. Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased respirations Widened pulse pressure Decreased body temperature Increased pulse
Widened pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
25. A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? subacute acute chronic intracerebral
acute Explanation: Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.
7. A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: nuchal rigidity and Kernig's sign. pupillary changes. motor loss in the legs that exceeds that in the arms. raccoon's eyes and Battle sign.
raccoon's eyes and Battle sign. Explanation: A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.
54. A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: to continue IV administration of other scheduled medications. payment status will change if the client isn't sedated. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. nutritional protocol will be effective after the client sedation therapy is tapered.
she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. Explanation: When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.
28. 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 sleeps for short periods of time. reports a headache. reports generalized weakness. vomits.
vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
