Chapter 45: PrepU - Nursing Management: Patients With Neurologic Trauma

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? 1- Herniation 2- Autoregulation 3- Cushing's response 4- Monro-Kellie hypothesis

1

At what rate (in drops per minute) should a nurse start an IV infusion if the order is for 1 g of vancomycin (Vancocin) to be given in 180 ml of dextrose 5% in water over 60 minutes? The tubing delivers 15 drops/ml. Enter the correct number only.

45

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? 1- Have the client avoid physical exertion 2- Emphasize complete bed rest 3- Look for signs of increased intracranial pressure 4- Look for a halo sign

3

Which condition occurs when blood collects between the dura mater and arachnoid membrane? 1- Intracerebral hemorrhage 2- Epidural hematoma 3- Extradural hematoma 4- Subdural hematoma

4

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin? 1- immediately 2- in 2 to 3 days 3- after 1 week 4- upon transfer to a rehabilitation unit

1

The initial sign of increasing intracranial pressure (ICP) includes 1- decreased level of consciousness. 2- herniation. 3- vomiting. 4- headache.

1

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? 1- Sciatic nerve pain 2- Herniation 3- Paresthesia 4- Paralysis

3

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? 1- Simple 2- Comminuted 3- Depressed 4- Basilar

4

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5 mL

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 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

A nurse assesses the patient's level of consciousness using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function? 1- 3 2- 6 3- 9 4- 15

1

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

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

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 1- reports a headache. 2- reports generalized weakness. 3- sleeps for short periods of time. 4- vomits.

4

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 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

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

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

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team? 1- spouse 2- chaplin 3- home care nurse 4- physical therapist

1

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

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

2

A patient is admitted to the emergency room with a skull fracture. The nurse notes a blood stain, surrounded by a yellowish ring, on the linens on the stretcher. The patient's respiratory system was stabilized at the site of the accident. Which of the following nursing interventions describes the immediate nursing action that needs to be taken? 1- Tell the patient not to blow his nose. 2- Put a note about avoiding the use of a suction catheter at the head of the bed. 3- Test the fluid leaking from the patient's ears for glucose. 4- Elevate the head of the bed 30 degrees.

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

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to 1- control fever. 2- control shivering. 3- dehydrate the brain and reduce cerebral edema. 4- reduce cellular metabolic demand.

3

A patient admitted for the treatment of a nondepressed skull fracture has been leaking clear fluid from his nose, and glucose testing confirms that it is cerebrospinal fluid (CSF). This development necessitates what nursing action? 1- Elevating the head of the bed to 30 degrees 2- Performing gentle nasal suctioning at 20 to 30 mm Hg 3- Insertion of a nasogastric (NG) tube to low suction 4- Positioning the patient side-lying

1

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

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

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? 1- Cardiogenic shock 2- Tetraplegia 3- Spinal shock 4- Paraplegia

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 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: 1- Coma 2- Absence of brain stem reflexes 3- Apnea 4- Glasgow Coma Scale of 6

4

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority? 1- Positioning to prevent complications 2- Maintenance of a patent airway 3- Assessment of pupillary light reflexes 4- Determination of the cause

2

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? 1- Decerebrate 2- Normal 3- Flaccid 4- Decorticate

1

A patient with amyotrophic lateral sclerosis (ALS) asks if the nurse has heard of a drug that will prolong the patient's life. The nurse knows that there is a medication that may prolong the life by 3 to 6 months. To which medication is the patient referring? 1- Baclofen 2- Riluzole 3- Dantrolene sodium 4- Diazepam

2

A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? 1- Placing the patient on a fluid restriction 2- Applying thigh-high elastic stockings 3- Administering an antifibrinolytic agent 4- Assisting the patient with passive range of motion exercises

2

A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC? 1- By assessing according to the Glasgow Coma Scale (GCS) 2- By eliciting the patient's response to a question requiring judgment 3- By engaging the patient in a conversation, if possible 4- By observing the patient's interactions with caregivers

1

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? 1- The client has cerebral spinal fluid (CSF) leaking from the ear. 2- The client has ecchymosis in the periorbital region. 3- The client has an elevated temperature. 4- The client has serous drainage from the nose.

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

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? 1- concussion 2- laceration 3- contusion 4- skull fracture

1

A client has been diagnosed with a frontal lobe brain abscess. Which nursing intervention is appropriate? 1- Assess for facial weakness. 2- Initiate seizure precautions. 3- Assess visual acuity. 4- Ensure that client takes nothing by mouth.

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

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

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? 1- Crust around the pin insertion site 2- A small amount of yellow drainage at the left pin insertion site 3- A slight reddening of the skin surrounding the insertion site 4- Pain at the insertion site

2

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? 1- Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. 2- Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. 3- Reassure the client that a headache is expected and will go away without treatment. 4- Notify the physician; a headache is an early sign of worsening neurologic status.

2

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 fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1- Decreased intravascular volume 2- Increased intracranial pressure (ICP) 3- Ischemic cerebrovascular accident (CVA) 4- Brain tissue necrosis

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

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

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

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: 1- naloxone (Narcan). 2- famotidine (Pepcid). 3- nitroglycerin (Nitro-Bid). 4- atracurium (Tracrium).

2

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

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 suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? 1- vasodilation 2- vasoconstriction 3- hypertension 4- increased PaO

1

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? 1- Irrigates the wound to remove debris 2- Administers an oral analgesic for pain 3- Administers acetaminophen (Tylenol) for headache 4- Shaves the hair around the wound

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

A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? 1- A brain lesion that causes a spontaneous response that changes with electrical activity in the brain 2- Cerebral hemisphere pathology that will cause alterations in flaccidity and contraction of motor responses 3- Decorticate positioning indicating damage to the upper midbrain 4- Decerebrate positioning implying severe dysfunction and brain pathology

4

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 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? 1- acute 2- chronic 3- subacute 4- intracerebral

1

A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following nursing diagnoses would be the first priority for the plan of care? 1- Ineffective airway clearance related to altered LOC 2- Risk of injury related to decreased LOC 3- Deficient fluid volume related to inability to take fluids by mouth 4- Risk for impaired skin integrity related to prolonged immobility

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

Which Glasgow Coma Scale score is indicative of a severe head injury? 1- 7 2- 9 3- 11 4- 13

1

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

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

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

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

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

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

4

Cerebral edema peaks at which time point after intracranial surgery? 1- 12 hours 2- 24 hours 3- 48 hours 4- 72 hours

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 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

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 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: 1- Increasing intracranial pressure (ICP) 2- An epidural hematoma 3- Leakage of cerebrospinal fluid (CSF) 4- Meningitis

3

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

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? 1- An epidural hematoma 2- An extradural hematoma 3- An intracerebral hematoma 4- A subdural hematoma

3

During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? 1- Place the patient in the supine position. 2- Administer diphenhydramine (Benadryl) for the allergic reaction. 3- Administer atropine to control the side effects of edrophonium. 4- Call the rapid response team because the patient is preparing to arrest.

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 most important nursing priority of treatment for a patient with an altered LOC is to: 1- Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. 2- Prevent dehydration and renal failure by inserting an IV line for fluids and medications. 3- Maintain a clear airway to ensure adequate ventilation. 4- Position the patient to prevent injury and ensure dignity.

3