Test 4

A client with a lumbar spinal injury would not require mechanical ventilation.

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.

At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return

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.

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.

An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain.

An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. A number of stimuli may trigger this reflex: distended bladder (the most common cause); distention or contraction of the visceral organs, especially the bowel (from constipation, impaction); or stimulation of the skin (tactile, pain, thermal stimuli, and pressure ulcer). The trigger is removed, and the patient is placed in a sitting position immediately to lower blood pressure.

Autonomic dysreflexia and respiratory infection are long-term complications of spinal cord injury. Respiratory arrest and spinal shock (areflexia) are immediate complications of spinal cord injury.

Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.

Which of the following medications is used in the treatment of diabetes insipidus to control fluid balance?

DDAVP is a synthetic vasopressin used to control fluid balance and prevent dehydration. Other medications that are used in the treatment of patients with diabetes insipidus include Diabinese, thiazide diuretics (potentiate action of vasopressin), and/or prostaglandin inhibitors such as ibuprofen and aspirin.

Diabetes insipidus (DI), the most common disorder of the posterior lobe of the pituitary gland, is characterized by a deficiency of antidiuretic hormone (ADH) (vasopressin). Excessive thirst (polydipsia) and large volumes of dilute urine characterize the disorder. Urine output may be as high as 20 L in 24 hours. Thirst is excessive and constant. Activities are limited by the frequent need to drink and void. Weight loss develops.

Eating, breathing, transferring to a wheelchair, and writing are functional abilities for those with a T4 injury.

The nurse is caring for a patient with TBI (traumatic brain injury). The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern?

Fever in the patient with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the patient'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

LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response.

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.

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

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.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

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.

Respiratory arrest and spinal shock are the immediate complications of spinal cord injury.

A nurse is caring for a client with syndrome of inappropriate antidiuretic hormone secretion (SIADH). Which of the following findings would indicate that the client has developed fluid overload?

Signs of fluid overload would include confusion, dyspnea, pulmonary congestion, and hypertension

Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing's reflex). As brain compression increases, respirations become rapid, the blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs.

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Stool softeners reduce the risk of straining during a bowel movement, which can increase ICP by raising intrathoracic pressure and interfering with venous return. Coughing also increases ICP

A patient with a traumatic brain injury is producing an abnormally large volume of dilute urine. Which alteration to a hormone secreted by the posterior pituitary would the nurse expect to find?

The most common disorder related to posterior lobe dysfunction is diabetes insipidus, a condition in which abnormally large volumes of dilute urine are excreted as a result of deficient production of vasopressin. Diabetes insipidus may occur following surgical treatment of a brain tumor, secondary to nonsurgical brain tumors, and traumatic brain injury.

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?

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.

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.

Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the patient may be diaphoretic, a fever does not accompany this condition.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

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

Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid

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 causes skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. Powder is not used inside the vest because it may contribute to the development of pressure ulcers.

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.

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?

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.

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