Prep U Ch. 68 Management of Patients With Neurologic Trauma
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
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.
The most important nursing priority of treatment for a patient with an altered LOC is to:
Maintain a clear airway to ensure adequate ventilation. Explanation: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.
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 Explanation: Most clients are hospitalized for at least 24 hours after a significant head injury. The nurse examines the client to identify signs of head trauma and tests drainage from the nose or ear. To detect any CSF drainage, the nurse looks for a halo sign, which is a blood stain surrounded by a clear or yellowish stain. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
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.
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?
Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
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 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
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
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.
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 Explanation: When a client reports numbness and tingling in an area, he 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
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?
Spinal shock Explanation: Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Subdural Explanation: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.
The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?
Temperature increase from 98.0°F to 99.6°F Explanation: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
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. 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.
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 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.
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
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. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.
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 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.
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with 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.
A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
Suction the airway. Explanation: Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
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 become rapid, 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.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
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. Options A, B, and C are not the most important parameters to monitor.
Which of the following is not a manifestation of Cushing's Triad?
Tachycardia Explanation: Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
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
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 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.
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
Which are risk factors for spinal cord injury (SCI)? Select all that apply.
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.
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?
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.
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
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.
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 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.
The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?
Edema to the head with bruising of the mastoid process Explanation: Battle's sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.
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 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.
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 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.
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Monitoring is needed as rapid neurologic deterioration may occur. Explanation: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
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. 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.
Which is the most common cause of spinal cord injury (SCI)?
Motor vehicle crashes Explanation: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.
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. 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.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?
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.
Neurological level of spinal cord injury refers to which of the following?
The lowest level at which sensory and motor function is normal Explanation: "Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal.
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:
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.
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?
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.
Which are characteristics of autonomic dysreflexia?
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.
Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?
Contusion Explanation: Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.
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?
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).
A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention?
maintain sufficient integument capillary pressure Explanation: Changing position every 2 hours relieves pressure over bony prominences and maintains sufficient capillary pressure to promote intact skin integrity.
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Loss of consciousness Explanation: The earliest sign of increasing ICP is loss of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma Explanation: Signs and symptoms include changes in the level of consciousness (LOC), changes in the reactivity of the pupils, and hemiparesis (weakness on one side of the body). There may be minor or even no symptoms, with small collections of blood. Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention.
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?
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).
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 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.
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply.
Bradycardia Hypertension Bradypnea Explanation: The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.
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 Explanation: An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
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 allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma Explanation: A subdural hematoma is a collection of blooding between the dura mater and brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with 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.
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 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.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6 Explanation: Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
Clinical manifestations of neurogenic shock include which of the following? Select all that apply.
Venous pooling in the extremities Bradycardia Warm skin Explanation: Loss of sympathetic innervation causes a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient doe not perspire on the paralyzed portions of the body because sympathetic activity is blocked.
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 Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site. Crust formation around the pin site is a natural response to the trauma caused by the pin insertion. Redness at the insertion site may be an early sign of infection; the nurse should continue to monitor the area, but this finding doesn't need to be reported to the physician. The client may experience pain at the pin insertion sites; therefore, the nurse should administer pain medications as ordered. It's necessary to notify the physician only if the pain medication is ineffective.
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 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.
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply.
Hypotension Venous pooling Tachypnea Hypothermia Explanation: The vital organs are affected in a spinal cord injury, causing the blood pressure and heart rate to decrease. This loss of sympathetic innervation causes a variety of other clinical manifestations, including a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the patient does not perspire on the paralyzed portions of the body because sympathetic activity is blocked; therefore, close observation is required for early detection of an abrupt onset of fever.
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is
Motor vehicle crashes Explanation: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.
The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
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.
