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A 36-year-old male patient is preparing for discharge from the hospital to a rehabilitative facility 4 weeks after he suffered a spinal cord injury (SCI) during a workplace accident. The hospital nurse should be aware that the primary focus of this coming phase of the patient's recovery will be: 1- Providing him with the skills to perform as many activities of daily living (ADLs) as possible 2- Ensuring that he adheres to the prescribed treatment regimen before being discharged home 3- Helping him establish therapeutic relationships with people who have had similar injuries 4- Allowing him to receive care in a setting that is less institutional than a hospital

1

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? 1- Take daily weights. 2- Reposition the client frequently. 3- Assess for pupillary response frequently. 4- Assess vital signs frequently.

1

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: 1- shivering in hypothermia can increase ICP. 2- hypothermia is indicative of severe meningitis. 3- hypothermia is indicative of malaria. 4- hypothermia can cause death to the client.

1

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? 1- Rebound hypotension 2- Rebound hypertension 3- Urinary tract infection 4- Spinal shock

1

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? 1- A bounding pulse 2- Bradycardia 3- Hypertension 4- Lethargy and stupor

4

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? 1- Extreme thirst 2- Intake and output 3- Nutritional status 4- Body temperature

4

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? 1- Insertion of a nasogastric (NG) tube 2- Urine testing for acetone 3- Serum sodium concentration testing 4- Out of bed to the chair three times a day

1

The diagnosis of multiple sclerosis is based on which test? 1- CSF electrophoresis 2- Magnetic resonance imaging 3- Evoked potential studies 4- Neuropsychological testing

2

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? 1- Extradural hematoma 2- Epidural hematoma 3- Subdural hematoma 4- Intracranial hematoma

2

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Bradypnea 3- Hypertension 4- Tachycardia

1,2,3

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? 1- Akathisia 2- Spasticity 3- Ataxia 4- Myoclonus

2

Which are risk factors for spinal cord injury (SCI)? Select all that apply. 1- Young age 2- Female gender 3- Alcohol use 4- Drug abuse 5- Caucasian ethnicity

1,3,4

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? 1- Decerebrate posturing and loss of corneal reflex 2- Loss of gag reflex and mental confusion 3- Complaints of headache and lack of pupillary response 4- Mental confusion and pupillary changes

1

A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? 1- Excessive urine output and decreased urine osmolality 2- Oliguria and decreased urine osmolality 3- Oliguria and serum hyperosmolarity 4- Excessive urine output and serum hypo-osmolarity

1

The nurse is caring for a client diagnosed with Guillain-Barre syndrome. His spouse asks about recovery rates. The nurse can correctly relate which of the following? 1- Approximately 60% to 75% of clients recover completely. 2- Only a very small percentage (5% to 8%) of clients recover completely. 3- Usually 100% of clients recover completely. 4- No one with Guillain-Barre syndrome recovers completely.

1

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? 1- Insertion of a nasogastric tube 2- A large volume enema 3- Digital stimulation 4- Bowel surgery

1

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? 1- Temperature increase from 98.0°F to 99.6°F 2- Urinary output increase from 40 to 55 mL/hr 3- Heart rate decrease from 100 to 90 bpm 4- Pulse oximetry decrease from 99% to 97% room air

1

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? 1- Check the equipment. 2- Contact the physician to review the care plan. 3- Continue the assessment because no actions are indicated at this time. 4- Document the reading because it reflects that the treatment has been effective.

1

Which are characteristics of autonomic dysreflexia? 1- severe hypertension, slow heart rate, pounding headache, sweating 2- severe hypotension, tachycardia, nausea, flushed skin 3- severe hypertension, tachycardia, blurred vision, dry skin 4- severe hypotension, slow heart rate, anxiety, dry skin

1

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. 1- Bradycardia 2- Hypertension 3- Bradypnea 4- Hypotension 5- Tachycardia

1,2,3

Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. 1- Decreased glucose 2- Increased protein 3- Increased white blood cells 4- Decreased protein 5- Increased glucose

1,2,3

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? 1- Fluid restriction 2- Vasopressin therapy 3- Hypertonic saline solution 4- Diet containing extra sodium

2

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. What medication does the nurse know will be given to prevent further spinal cord damage? 1- Furosemide (Lasix) 2- Methylprednisolone (Solu-Medrol) 3- Cyclobenzaprine (Flexeril) 4- Hydralazine hydrochloride (Apresoline)

2

A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for: 1- An area of bruising over the mastoid bone 2- Bleeding from the ears 3- An increase in pulse 4- Difficulty sleeping

2

Episodes of orthostatic hypotension occur in the first 2 weeks after a spinal cord injury. Compare the two blood pressure measurement for each answer. The blood pressure reading obtained when the patient was sitting, is in the left column for comparison. Which of the following shows the blood pressure measurement indicative of orthostatic hypotension? 1- 140/110 130/110 2- 140/100 120/90 3- 130/90 125/85 4- 130/80 120/80

2

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? 1- Continuous use of an indwelling catheter 2- Meticulous cleanliness 3- Avoidance of all lotions and lubricants 4- Allowing the client to choose the position of comfort

2

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)? 1- Position the client in the supine position 2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg 3- Restrain the client, as indicated 4- Administer enemas, as needed

2

The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis? 1- Increased cardiac biomarkers 2- Hypotension 3- Tachycardia 4- Excessive sweating

2

A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? 1- Maintaining adequate hydration 2- Administering prescribed antipyretics 3- Restricting fluid intake and hydration 4- Hyperoxygenation before and after tracheal suctioning

3

The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? 1- Babinski sign 2- Kernig's sign 3- Battle's sign 4- Brudzinski's sign

3

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? 1- "I will change the vest liner periodically." 2- "If a pin becomes detached, I'll notify the surgeon." 3- "I can apply powder under the liner to help with sweating." 4- "I'll check under the liner for blisters and redness."

3

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? 1- Hypophysectomy 2- Application of Halo traction 3- Burr holes 4- Insertion of Crutchfield tongs

3

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? 1- Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction 2- Ineffective cerebral tissue perfusion related to increased intracranial pressure 3- Disturbed thought processes related to brain injury 4- Ineffective airway clearance related to brain injury

4

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? 1- Monro-Kellie 2- Cushing's 3- Dawn phenomenon 4- Hashimoto's disease

1

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered

4

A client with a spinal cord injury has full head and neck control when the injury is at which level? 1- C1 2- C2 to C3 3- C4 4- C5

4

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? 1- Occipital skull fracture 2- Temporal skull fracture 3- Frontal skull fracture 4- Basilar skull fracture

4

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? 1- Examine the skin for any area of pressure or irritation. 2- Examine the rectum for a fecal mass. 3- Empty the bladder immediately. 4- Raise the head of the bed and place the patient in a sitting position.

4