Chapter 22 Head and Spinal Cord Injuries EAQ

The nurse is caring for a patient with an epidural hematoma. What important nursing intervention will help to prevent increased intracranial pressure? 1 Keep the patient's head flat. 2 Keep the patient turned on the right side. 3 Keep the patient turned on the left side. 4 Keep the head raised 20 to 30 degrees with the body in correct alignment.

Keep the head raised 20 to 30 degrees with the body in correct alignment. The head should be raised 20 to 30 degrees with the body in correct alignment to prevent increased intracranial pressure. Keeping the patient's head flat or turning the patient to the right or left side may increase intracranial pressure.

A nurse is caring for a patient 8 hours after a thoracic spinal cord injury; this patient has not entered spinal shock. The nurse will know that spinal shock has begun when which physiologic change occurs? 1 All reflexes in the body disappear 2 Hyperreflexia occurs caudal to the lesion 3 Hyperreflexia occurs medial to the lesion 4 Loss of reflex activity and sensation below the level of injury

Loss of reflex activity and sensation below the level of injury Spinal shock is characterized by flaccid paralysis and loss of reflex activity and of sensation below the level of the injury. Spinal shock occurs immediately after injury and lasts 48 hours to several weeks. All reflexes in the body do not disappear in a thoracic spinal cord injury. Spinal shock is characterized by hyporeflexia, not hyperreflexia.

A nurse in the emergency department is preparing for the arrival of a patient with a high cervical injury. The nurse expects this patient, if he survives, to suffer from which condition? 1 Paraplegia 2 Hemiplegia 3 Tetraplegia 4 Normoplegia

Tetraplegia Tetraplegia, formerly called quadriplegia, is the paralysis of all limbs that results from a high cervical injury. Paraplegia is the paralysis of the lower limbs that occurs after a lower spinal cord injury. Hemiplegia is the paralysis of either the right or left side of the body resulting from a stroke. Normoplegia is not a condition.

Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head? 1 The 76-year-old patient who is taking an anticoagulant 2 The 16-year-old football player who suffered a concussion 3 The 36-year-old patient who has a history of migraine headaches 4 The 56-year-old patient who is taking an antihypertensive medication

The 76-year-old patient who is taking an anticoagulant A subdural hematoma results when blood leaks under the dura mater (subdural) and presses against the softer arachnoid membrane and the brain tissue it is covering. As blood leaks, the hematoma grows in size. The 76-year-old patient is most at risk for a subdural hematoma due to his anticoagulant medication. The football player who suffered a concussion is at an increased risk for a head bleed, but less so than the elderly patient taking anticoagulant medication. The patients with migraine headaches and antihypertensive medications are not at an increased risk for hemorrhage.

A patient is admitted to the intensive care unit after a craniotomy. What should be reported immediately because it is an indication of increasing intracranial pressure? Select all that apply. 1 Projectile vomiting 2 Changes in vital signs 3 Slight restlessness after visiting hours 4 Leaking of cerebrospinal fluid from the nose or ear 5 Deepening stupor and decreasing level of consciousness

Projectile vomiting 2 Changes in vital signs Leaking of cerebrospinal fluid from the nose or ear 5 Deepening stupor and decreasing level of consciousness The leakage of cerebrospinal fluid from the nose or ear, projectile vomiting, changes in vital signs, and deepening stupor and decreasing level of consciousness should be reported immediately, because they indicate increasing intracranial pressure. Extreme restlessness or excitability after a period of apparent calm, not slight restlessness after visiting hours, should be reported immediately, because it also indicates increasing intracranial pressure.

The patient who had a laminectomy following a herniated lumbar disc is preparing to be discharged. Which statement by the patient indicates a need for additional discharge instructions? 1 "I should try to maintain a normal weight." 2 "It is best for me to do my back exercises twice a day." 3 "I need to be sure not to twist or bend at the waist when lifting things." 4 "I can take a 4-hour car ride, as long as I stay perfectly still."

"I can take a 4-hour car ride, as long as I stay perfectly still." Standing and sitting for long periods is discouraged for several weeks following a laminectomy; the patient should be encouraged to stop and walk around at least every 2 hours. The patient would be correct in stating he should try to maintain a normal weight, do back exercises twice a day, and avoid twisting or bending at the waist when lifting.

A 13-year-old female patient has been seen in a walk-in clinic following a blow to the head from a fall during basketball practice. Which statement by the parent indicates the need for further discharge teaching? 1 "I need to wake her up every 2 or 3 hours for the first 24 hours." 2 "I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." 3 "I need to check her pupils frequently with a flashlight to be sure her pupils constrict." 4 "I need to watch for any changes in the level of consciousness or vomiting for 48 hours."

"I need to apply ice to the bump on her head for 20 minutes every hour for 72 hours." Ice should be applied to the area of injury for the first 24 hours for 20 minutes intervals every hour the patient is awake, not 72 hours. All other instructions are correct. The reason for waking the patient every 2 or 3 hours is to ensure she is easily aroused at those times, which helps demonstrate the LOC.

The nurse is caring for a patient with a cervical spine injury. The patient's family asks the nurse why Crutchfield tongs for traction are being used. What is the most accurate response by the nurse? 1 "This type of traction is used to relieve intracranial pressure." 2 "This type of traction is used to keep the vertebrae in alignment." 3 "This type of traction is used to allow for safe turning of the patient by splinting the head and neck." 4 "This type of traction is used to provide a means of relieving the pressure of blood within the skull."

"This type of traction is used to keep the vertebrae in alignment." Cervical spinal cord injury is sometimes treated with traction to immobilize the affected vertebrae and maintain alignment. Traction can be accomplished by skeletal traction using Crutchfield or Gardner-Wells tongs with ropes, pulleys, and weights or a halo ring and fixation pins. This type of traction is not used to relieve intracranial pressure, splint the head and neck, or relieve pressure of blood within the skull.

All the following are levels of consciousness. Starting with the optimal level of consciousness, place these in order of a decreasing level of consciousness. 1. Alert 2. Confused 3. Lethargic 4. Stuporous 5. Obtunded 6. Comatose

. Alert 2. Confused 3. Lethargic 4. obtunded 5. Stuporous 6. Comatose

The nursing student recognizes that skull fractures are described with the use of which terms? Select all that apply. 1 Closed 2 Depressed 3 Comminuted 4 Hyperextended 5 Coup-contrecoup

1 Closed 2 Depressed 3 Comminuted Skull fractures are described as closed or open; depressed or linear; and simple, comminuted, or compound. Hyperextended is a positional description, and coup-contrecoup is a brain content injury.

How is the severity of brain damage initially determined? Select all that apply. 1 The urologic assessment 2 The history of the type of blow received 3 The symptoms presented by the patient 4 Whether the victim is an organ donor or not 5 Whether and for how long the victim lost consciousness

2 The history of the type of blow received 3 The symptoms presented by the patient Whether and for how long the victim lost consciousness The severity of brain damage is initially determined by the symptoms presented by the patient, the history of the type of blow received, and whether and for how long the victim lost consciousness. The neurologic assessment, not the urologic assessment, is important initially. Whether the victim is an organ donor is unimportant when initially determining the severity of brain damage.

During a patient care planning conference, the goal of patient care is identified as keeping the intracranial pressure (ICP) low enough to allow adequate cerebral perfusion pressure. The nurse identifies which value as the minimum cerebral perfusion pressure (CPP) that ensures adequate cerebral functioning? 1 10 to 20 mm Hg 2 20 to 30 mm Hg 3 30 to 40 mm Hg 4 60 to 70 mm Hg

60 to 70 mm Hg A patient with an elevated ICP may have decreased cerebral perfusion pressure. A minimum perfusion pressure of 60 to 70 mm HG is necessary to ensure adequate cerebral functioning.

A nurse arrives first at the scene of a motor vehicle accident. If the nurse suspects that the patient has a spinal cord injury, what should be done? Select all that apply. 1 Assess the scene for safety and the patient's condition. 2 Immediately remove the patient from the scene of the accident. 3 Avoid flexion of the neck by using a pillow under the patient's head. 4 Avoid moving the patient unless life-threatening conditions require it. 5 Transfer the patient to the hospital in the back seat of the largest vehicle available.

Assess the scene for safety and the patient's condition. Avoid moving the patient unless life-threatening conditions require it. The nurse should always assess the scene for safety and assess the patient's condition upon arrival at the scene of a motor vehicle accident. Avoid movement of the patient unless life-threatening conditions require it. Avoidance of flexion of the neck by not using a pillow is important. The transfer of a patient who is suspected of having a spinal cord injury should be done by trained emergency medical technicians.

A head injury patient has bruising behind the ear. The nursing student understands that this is called what? 1 Halo sign 2 Battle sign 3 Raccoon eyes 4 Babinski sign

Battle sign Bruising behind the ear that occurs after a head injury is called Battle sign. The halo sign is used to determine whether drainage from the nose or ear is cerebral spinal fluid. Raccoon eyes refers to ecchymosis that occurs around the eyes as a result of a skull fracture. The Babinski reflex is used as part of a neurologic assessment.

What are the classic signs of increased intracranial pressure? Select all that apply. 1 Chest pain 2 Bradycardia 3 Irregular respirations 4 Narrowing pulse pressure 5 Rising systolic blood pressure

Bradycardia Irregular respirations Rising systolic blood pressure The classic signs of increased intracranial pressure include bradycardia with a full, bounding pulse, rapid or irregular respirations, rising systolic blood pressure, and widening pulse pressure. Chest pain is not related to increased intracranial pressure; it is more often associated with lung or heart problems.

A nurse working in the emergency department is notified that the ambulance is en route to the aid of a child who landed on his head after jumping off a trampoline. Thirty minutes later, the child arrives and is pronounced dead. The EMT reports that the child was not breathing when the team arrived and that they were unable to restart the patient's respirations. The nurse knows that the child likely suffered a spinal cord injury above which level? 1 C5 2 C3 3 T1 4 T2

C5 The diaphragm is enervated by the phrenic nerve, which is formed by the C1 to C4 nerve roots. This means that spinal cord injuries at level C5 and above may cause respirations to cease, resulting in immediate death. Spinal cord injuries below the level of C5 may not result in immediate death.

A nurse is caring for a patient with a spinal cord injury at the T3 level. The patient is resting comfortably when the vitals monitor alarms. The nurse sees the patient's blood pressure has increased severely, the heart rate has decreased rapidly, and the patient is flushed and diaphoretic. What would be the nurse's priority intervention? 1 Call the code team 2 Check the indwelling catheter for kinks 3 Increase oxygen flow through the nasal cannula 4 Perform a rectal examination to check for fecal impaction

Check the indwelling catheter for kinks Autonomic dysreflexia can be caused by bladder distention, constipation, and many other stimulations below the level of the spinal cord injury. The nurse should first check the indwelling catheter for kinks, because this is the quickest and least invasive intervention. It may be necessary to perform a rectal examination to check for fecal impaction if there are no kinks in the patient's indwelling catheter. If no precipitating factor is found, it may be necessary to call a code. If the patient's oxygen saturation decreases, the nurse should increase the patient's oxygen flow with a primary health care provider's prescription.

A patient underwent cranial surgery. What actions should the nurse perform to prevent increased intracranial pressure (ICP)? Select all that apply. 1 Closely monitor fluid and electrolyte levels. 2 Turn and position the patient appropriately. 3 Assess the patient's weight loss after surgery. 4 Frequently assess the patient's neurologic status. 5 Monitor the patient's serum creatinine and lipid profile.

Closely monitor fluid and electrolyte levels. 2 Turn and position the patient appropriately. Frequently assess the patient's neurologic status. With the head of the bed at 20 to 30 degrees, the head and neck must be kept positioned midline so that venous drainage into the body is not restricted. Hip flexion should be less than 90 degrees. Rolled washcloths, towels, or trochanter rolls can be used for positioning. The patient should be turned and positioned appropriately and carefully to prevent an increase in ICP. Frequent assessment of the patient's neurologic status is essential during the first 48 hours after the cranial surgery. "Neuro checks" are performed every 15 minutes to every 2 hours for the acute patient. Close monitoring of fluid and electrolyte levels is important. Assessing the patient's weight loss after surgery and monitoring the patient's serum creatinine and lipid profile are not the prime interventions after any cranial surgery, because they do not affect the ICP.

A patient has a head injury, and fluid begins to leak from his nose. To determine if the leakage is spinal fluid, the LPN/LVN should check the fluid for which substance? 1 Blood 2 Protein 3 Glucose 4 Acetone

Glucose Glucose is found in spinal fluid. Testing with a Dextrostix will determine whether glucose is present. It is not necessary to test the leaking substance for blood, protein, or acetone.

After a head injury, the patient begins to have drainage from the nose. The nurse assesses the drainage by which method? 1 Halo test 2 Tinel sign 3 Battle sign 4 Babinski sign

Halo test The halo test is used to determine whether drainage from the nose or ear is cerebral spinal fluid. Tinel sign is one assessment used during the assessment of carpal tunnel symptoms. Bruising behind the ear that occurs after a head injury is called Battle sign. Babinski sign is checked as part of a neurologic assessment.

The nurse is caring for a patient with a head injury. Which activity will the nurse want to ensure? 1 Coughing 2 Head flexion 3 Valsalva maneuver 4 Head of bed elevated to 20 degrees

Head of bed elevated to 20 degrees The head of the bed should be elevated to 20-30 degrees. This position helps promote venous drainage from the head and prevents further swelling from positioning the patient inappropriately. Coughing, head flexion, and Valsalva maneuvers all increase intracranial pressure and should be avoided.

A patient presents with a headache, which is worse in the morning and is aggravated with movements. The patient also complains of vomiting without any preceding nausea. When assessing the patient, which common causes should the nurse consider when suspecting increased intracranial pressure? Select all that apply. 1 Sinusitis 2 Glaucoma 3 Hematoma 4 Head injury 5 Brain tumor

Hematoma 4 Head injury 5 Brain tumor Common causes of increased intracranial pressure include a masslike hematoma or tumor and cerebral edema caused by brain tumors or hydrocephalus, head injury, or brain inflammation. Sinusitis and glaucoma do not cause an increase in intracranial pressure.

What is the priority concern that the nurse has regarding the care of a person with a C2 injury? 1 Loss of control of upper body 2 Loss of bowel and bladder control 3 Inability to move without assistance 4 Inability to breathe without respiratory assistance

Inability to breathe without respiratory assistance The priority concern that the nurse has regarding the care of a person with a C2 injury is the patient's inability to breathe without respiratory assistance. Loss of control of the upper body, loss of bowel and bladder control, and the inability to move without assistance are all concerns, but these are not the priority concerns for the nurse.

A patient with a head injury presents to the emergency department. Which potential complication related to cerebral hemorrhage and edema should the nurse evaluate this patient for? 1 Anxiety 2 Hyperthermia 3 Impaired physical mobility 4 Increased intracranial pressure

Increased intracranial pressure Increased intracranial pressure can occur as a potential complication related to cerebral hemorrhage and edema. Anxiety can result from an abrupt change in health status, being in a hospital environment, and having an uncertain future. Hyperthermia can be caused by increased metabolism, infection, and hypothalamic injury. Impaired physical mobility is related to a decreased level of consciousness.

What psychological concern is associated with a patient who sustains a spinal cord injury with quadriplegia? 1 Immobilization 2 Bowel and bladder distention 3 Risk for deep venous thrombosis 4 Loss of role in family and lifestyle

Loss of role in family and lifestyle A major psychological concern associated with a patient who sustains a spinal cord injury with quadriplegia is the grief related to the loss of his or her role in the family and his or her former lifestyle. Immobilization, bowel and bladder function, and the risk for deep venous thrombosis can cause psychological distress, but they are physical concerns that cause psychological concerns.

When managing a patient with increased intracranial pressure (ICP), which actions should the nurse perform? Select all that apply. 1 Monitor fluid and electrolyte levels. 2 Administer intubation and mechanical ventilation. 3 Lower the head of the bed and turn the patient to one side. 4 Wait for the respiration to improve before beginning with ventilation. 5 Elevate the head of the bed to 30 degrees with the head in a neutral position.

Monitor fluid and electrolyte levels. Administer intubation and mechanical ventilation. Elevate the head of the bed to 30 degrees with the head in a neutral position. Intubation and mechanical ventilation, monitoring fluid and electrolyte levels, and elevation of the head of the bed to 30 degrees with the head in a neutral position are the appropriate actions to be performed when managing a patient with increased ICP. Waiting for the respirations to improve may be life-threatening. Lowering of head of bed and turning the patient to one side may further increase the intracranial pressure.

The nurse is caring for a patient with a head injury who has an intracranial pressure monitor in place. Assessment reveals an ICP reading of 66. What is the best nursing action? 1 Notify the physician. 2 Document the reading. 3 Place the patient in a supine position.

Notify the physician. Normal ICP is 0 to 15 mm Hg; 66 is an extremely high reading. The physician should be notified. The reading should be documented once the patient is safe. The patient with elevated ICP should never be placed in the supine position, which increases ICP further. Repositioning the patient increases intracranial pressure and should be avoided.

Papilledema is a classic sign of increased cranial pressure. The nurse explains to the nursing student that papilledema can be assessed with the use of what method? 1 Observing during skin assessment 2 Observing with an ophthalmoscope 3 Palpating around the orbital bone and socket 4 Palpating the cranium, particularly around the ears

Observing with an ophthalmoscope Papilledema (swelling of the optic disc) is viewed with an ophthalmoscope. It is one of the classic signs of increased cranial pressure. The optic disc cannot be palpated nor observed with any method other than the ophthalmoscope.

Which term is used to describe the swelling of the optic disc? 1 Contusion 2 Concussion 3 Papilledema 4 Nuchal rigidity

Papilledema Papilledema is the term used to describe the swelling of the optic disc caused by increased intracranial pressure. Contusion occurs when tissue is bruised; edema develops when blood from broken vessels accumulates. Concussion is the term used to describe a closed head injury in which there is a brief disruption in level of consciousness (LOC), amnesia regarding the occurrence, and headache. Nuchal rigidity causes neck pain with flexion. It generally occurs due to bleeding into the subarachnoid space or meningitis.

A patient with elevated intracranial pressure (ICP) is at risk for lower cerebral perfusion pressure (CPP) during suctioning. The nurse should maintain CPP above how many mm Hg to preserve cerebral perfusion? Record your answer using whole numbers. _____ mm Hg

Patients with elevated ICP are at risk for lower CPP during suctioning. CPP must be maintained at 50 to 70 mm Hg to ensure oxygenation of the brain tissue (CPP = mean arterial pressure - intracranial pressure). Normal CPP is 70 to 100 mm Hg.

A nurse is caring for a patient who suffered a high cervical spinal cord injury and must be mechanically ventilated because the diaphragm is no longer stimulated. However, the nurse knows that an implant that stimulates which nerve can help stimulate diaphragmatic movement and improve respirations? 1 Phrenic nerve 2 Brachial plexus 3 Trigeminal nerve 4 Intercostal nerve

Phrenic nerve The phrenic nerve facilitates respiration by stimulating the diaphragm to move. A phrenic nerve implant can stimulate the diaphragm and improve respiration. The brachial plexus, trigeminal nerve, and intercostal nerve do not drive respiration.

A halo traction vest has been applied to a patient who sustained a fracture of the spinal vertebrae. The patient asks the nurse to explain the purpose of this device. What response should the nurse give? 1 Reduced cost 2 Reduced risk for infection 3 Reduced risk for spinal cord injury 4 Reduced risk for body image concerns

Reduced risk for spinal cord injury Halo traction is used to prevent cervical spinal cord injury after a spinal vertebral fracture. It allows some mobility. There is a reduction in cost and the potential for infection risk because surgery is not done. Halo traction is not optimal for reducing body image concerns.

The nurse is careful when moving the patient who is tetraplegic because muscle spasms can occur. The nurse should anticipate muscle spasms and help the family to understand that these will occur, because family members sometimes misinterpret these spasms in which way? 1 Painful and demand pain medications be given 2 Seizure activity and may try to hold patient down 3 Return of voluntary function and have false hopes of full recovery 4 Return of involuntary movement and have false hopes of full recovery

Return of voluntary function and have false hopes of full recovery Sometimes family members may misinterpret these strong involuntary contractions of the muscles or muscle spasms as a return of voluntary function and have false hopes of full recovery.

A nurse is caring for a patient who is experiencing spastic paralysis. Which priority intervention would the nurse include in the patient's care during this period? 1 Ensure adequate pain control. 2 Encourage the patient to participate in rehabilitation. 3 Perform range-of-motion exercises several times per day. 4 Secure a strap across the patient's chest when using a wheelchair.

Secure a strap across the patient's chest when using a wheelchair. During the period of spastic paralysis, the patient can spasm so violently that he or she is thrown from the wheelchair. Therefore, during this period, it is most important to secure the patient to the wheelchair to keep the patient safe. Ensuring adequate pain control is always an important intervention, but it is not the priority at this time. Depending on the plan of care, it may be important to encourage participation in rehabilitation therapy and perform range-of-motion exercises, but safety is of utmost importance.

When teaching a patient about care after a head injury, which important symptoms should the nurse instruct the patient and caregiver to immediately notify the primary health care provider about? Select all that apply. 1 Seizures 2 Sneezing 3 Stiff neck 4 Constipation 5 Increased drowsiness

Seizures Stiff neck Increased drowsiness Seizures, a stiff neck, and increased drowsiness are the important symptoms that the patient and caregivers should immediately relay to the primary health care provider. Sneezing and constipation are not alarming and can also have other causes.

The patient is receiving mannitol as part of the treatment for increased intracranial pressure (ICP). Which lab value will be most important for the nurse to assess? 1 Serum glucose 2 Serum electrolytes 3 Arterial blood gases (ABGs) 4 Hemoglobin and hematocrit (Hb and HCT)

Serum electrolytes Mannitol is an osmotic diuretic used to rapidly reduce ICP. Because its effects can be rapid and excessive, the patient needs to be monitored for electrolyte imbalance. The patient should also be assessed for signs of dehydration and changes in vital signs. Serum glucose, ABGs, and Hb and Hct should all be monitored but are of less importance than serum electrolytes.

The plan of care for a patient with a spinal cord injury mentions observations of autonomic dysreflexia. Which symptoms should the nurse observe? Select all that apply. 1 Severe headache 2 Sudden hypotension 3 Changes in respiratory rate, with apneic episodes 4 Pallor and "goose bumps" below the level of injury 5 Sweating and flushing above the level of the spinal cord lesion

Severe headache Pallor and "goose bumps" below the level of injury Sweating and flushing above the level of the spinal cord lesion Symptoms of autonomic dysreflexia include severe headache, changes in pulse rate (not respiratory rate), pallor and "goose bumps" below the level of injury, sweating and flushing above the level of the spinal cord lesion, and sudden hypertension with subsequent seizure, retinal hemorrhage, or stroke.

A nurse is caring for a patient with flaccid paralysis, which is characteristic of spinal shock, caused by complete transection of the spinal cord. The nurse knows that spinal shock is considered resolved when which event occurs? 1 Tone decreases in paralyzed areas. 2 Motor function returns in paralyzed areas. 3 Sensory function returns in paralyzed areas. 4 Spastic, involuntary movements of extremities occur. 00:02:17 Question Answer Confidence ButtonsJust a guessPretty sureNailed it

Spastic, involuntary movements of extremities occur. Spinal shock is resolved when spastic paralysis sets in, which is characterized by spastic, involuntary movements of the extremities. In flaccid paralysis, there is no muscle tone; therefore it is not possible for the tone to decrease further. The patient's injury is a complete transection of the spinal cord; therefore the patient will not regain sensory or motor function.

A patient is bought in by ambulance with a suspected brain injury. What are the outward symptoms of head injury? Select all that apply. 1 Tinnitus 2 Diarrhea 3 Otorrhea 4 Battle sign 5 Chvostek sign

Tinnitus Otorrhea Battle sign The outward symptoms of head injury include tinnitus, otorrhea, and Battle sign. Diarrhea is not a symptom of head injury. Chvostek sign is used to assess for hypocalcemia.

A patient presents to the emergency department with a C7 spinal cord injury. Which activities would be possible for the patient to perform? Select all that apply. 1 Transfer to and from a chair 2 Have excellent bed mobility 3 Perform self-catheterization 4 Manipulate a wheelchair with the arms 5 Exhibit independence in most activities of daily living (ADLs)

Transfer to and from a chair 2 Have excellent bed mobility 4 Manipulate a wheelchair with the arms 5 Exhibit independence in most activities of daily living (ADLs) A C7 spinal cord injury affects the shoulder, elbow, wrist, hand, and partial movements and possibly causes paraplegia. The patient may be able to manipulate a wheelchair with the arms, transfer to and from a chair, drive a specially fitted car, have excellent bed mobility, and be independent in most ADLs. A C8 injury patient can perform self-catheterization.

The student nurse is assisting the nurse in turning a patient who is in cervical traction. What is most important for the LPN/LVN to instruct the student to do when assisting in turning the patient? 1 Flex the knees and hips before turning the patient. 2 Support the patient's head with a pillow so that his neck is flexed. 3 Turn the patient slowly and as one unit to avoid twisting the spine. 4 Place the patient's back in traction so that the spine will be kept slightly flexed.

Turn the patient slowly and as one unit to avoid twisting the spine. One of the most important interventions when turning a patient in traction, or turning any patient with a spinal cord injury, is to log roll the patient in order to avoid twisting the vertebral column and further damaging the spinal cord. Nurses should always assist in turning a patient with a spinal cord injury; this intervention should never be delegated to assistive personnel.

The emergency department nurse assesses the patient and suspects that there is an acute intracerebral bleed causing a hematoma. What are the specific symptoms of this condition? Select all that apply. 1 Unconsciousness 2 Nausea and vomiting 3 Battle sign and nuchal rigidity 4 Dilated pupil on the ipsilateral side 5 Hemiplegia on the contralateral side

Unconsciousness Dilated pupil on the ipsilateral side Hemiplegia on the contralateral side An acute intracerebral bleed causing a hematoma has symptoms that include unconsciousness, a dilated pupil on the ipsilateral side, and hemiplegia on the contralateral side. Nausea and vomiting are associated with an epidural hematoma. Battle sign and nuchal rigidity are associated with head injury.

What signs are considered "Cushing triad"? Select all that apply. Incorrect1 Rising pulse rate 2 Widening pulse pressure 3 Sudden rise in temperature 4 Lowering systolic blood pressure 5 Bradycardia with a full, bounding pulse

Widening pulse pressure Bradycardia with a full, bounding pulse The classic signs of Cushing triad are rising systolic blood pressure, widening pulse pressure, and bradycardia with a full, bounding pulse.

What condition can increase the risk for torn vessels and contusion on the brain if an accident that involves brain injury occurs? 1 Brain atrophy 2 Hydrocephalus 3 Heterotopic ossification

brain atrophy Brain atrophy (shrinkage in size) can occur with aging and places the person at risk for torn vessels and contusion on the brain in the event of an accident with brain injury. Increased intracranial pressure and hydrocephalus can both provide cushion to the brain in the event of an accident that involves brain injury. Both of those conditions could occur as a result of a brain injury, but they would not place the patient at more risk for torn vessels or contusion on the brain like brain atrophy would. Heterotopic ossification may occur with long-term immobility; this is a bony overgrowth that may involve muscle, and it is considered a long-term complication of spinal injury.