Chapter 63

A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? A. Assessing all body surfaces and documenting skin integrity every 8 hours B. Turning and repositioning the client every 6 hours C. Providing skin care with barrier care ointments once a day D. Assisting the client to get out of bed to a chair four times a day.

A. Assessing all body surfaces and documenting skin integrity every 8 hours

The nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. The nurse knows that this could be a symptom of which complication of a spinal cord injury? A. Autonomic dysreflexia B. Spinal shock C. Retinal hemorrhage D. Myocardial infarction

A. Autonomic dysreflexia

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this? A. Baclofen B. Dexamethasone C. Mannitol D. Phenobarbital

A. Baclofen

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk? A. Change the client's position frequently. B. Provide a high-protein diet. C. Provide light massage at least daily. D. Teach the client deep breathing and coughing exercises.

A. Change the client's position frequently.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first? A. Check the client's indwelling urinary catheter for kinks to ensure patency. B. Lower the HOB to improve perfusion. C. Administer PRN analgesia as prescribed. D. Reassure the client that headaches are expected during recovery from spinal cord injuries.

A. Check the client's indwelling urinary catheter for kinks to ensure patency.

The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform? A. Ensure that the player is not moved. B. Obtain the player's vital signs, if possible. C. Perform a rapid assessment of the player's range of motion. D. Assess the player's reflexes.

A. Ensure that the player is not moved.

The emergency room (ER) nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding(s) are suggestive of a basilar skull fracture? Select all that apply A. Epistaxis B. Swelling of the tongue and lips C. Bruising over the mastoid D. Unilateral facial numbness E. Severe back pain

A. Epistaxis C. Bruising over the mastoid

An 82-year-old client is admitted for observation after a fall. Due to the client's age, the nurse knows that the client is at increased risk for what complication of his injury? A. Hematoma B. Skull fracture C. Embolus D. Stroke

A. Hematoma

The nurse is caring for a client with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage? A. Hyperthermia B. Tachycardia C. Hypertension D. Bradypnea

A. Hyperthermia

A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure? A. Magnetic resonance imaging (MRI) B. Positron emission tomography (PET) scan C. X-ray of the head D. Ultrasound of the head

A. Magnetic resonance imaging (MRI)

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply. A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT D. Salt-wasting syndrome E. Increased ICP

A. Orthostatic hypotension B. Autonomic dysreflexia C. DVT

A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? A. Pneumonia, pulmonary embolism, and sepsis B. Cardiac tamponade, hypoxia, and malnutrition C. Oxygen toxicity in paralytic ileus and electrolyte imbalances D. Seizures, osteomyelitis, and urinary tract infections

A. Pneumonia, pulmonary embolism, and sepsis

A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? A. Urinary catheter use often leads to urinary tract infections (UTIs). B. Urinary function is permanently lost following an SCI. C. Urinary catheters should not remain in place for more than 7 days. D. Overuse of urinary catheters can exacerbate nerve damage.

A. Urinary catheter use often leads to urinary tract infections (UTIs).

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply. A. Young age B. Frequent travel C. African American race D. Male gender E. Alcohol or drug use

A. Young age D. Male gender E. Alcohol or drug use

The three cardinal signs of brain death on clinical examination are coma, the absence of brainstem reflexes, and ________________.

Apnea

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This provides what potential information to the nurse about the client's status? A. The client's level of knowledge about preceding events B. An assessment of the client's current level of consciousness C. An assessment of the client's lowest verbal and physical response to stimuli D. An in-depth and real-time neurological assessment of the client's condition

B. An assessment of the client's current level of consciousness

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal sign(s) of brain death? Select all that apply. A. Absence of pain response B. Apnea C. Coma D. Absence of brain stem reflexes E. Absence of deep tendon reflexes

B. Apnea C. Coma D. Absence of brain stem reflexes

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? A. Respiratory distress and projectile vomiting B. Bradycardia and hypertension C. Tachycardia and agitation D. Third-spacing and hyperthermia

B. Bradycardia and hypertension

A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? A. Seizure prophylaxis and prevention B. Cervical and spinal immobilization C. Fluid and electrolyte maintenance, D. Intubation and mechanical ventilation

B. Cervical and spinal immobilization

Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action? A. Complete the pin site care to decrease risk of infection. B. Notify the neurosurgeon of the occurrence. C. Stabilize the head in a lateral position. D. Reattach the pin to prevent further head trauma.

B. Notify the neurosurgeon of the occurrence.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? A. Prepare to transfuse packed red blood cells. B. Prepare for interventions to increase the client's BP. C. Place the client in the Trendelenburg position. D. Prepare an ice bath to lower core body temperature.

B. Prepare for interventions to increase the client's BP.

A client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 11/2 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure? A. Risk for impaired skin integrity B. Risk for injury C. Risk for autonomic dysreflexia D. Risk for suffocation

B. Risk for injury

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? A. Preparation for emergency craniotomy B. Watchful waiting and close monitoring C. Administration of inotropic drugs D. Fluid resuscitation

B. Watchful waiting and close monitoring

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following? A. Keep the head of the bed (HOB) flat at all times. B. Teach the client to perform the Valsalva maneuver. C. Administer benzodiazepines on a PRN basis. D. Perform endotracheal suctioning every hour.

C. Administer benzodiazepines on a PRN basis.

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation." What action should the nurse implement? A. Administer a benzodiazepine at bedtime each night. B. Do not disturb the client between 2200 and 0600. C. Cluster overnight nursing activities to minimize disturbances. D. Ensure that the client does not sleep during the day.

C. Cluster overnight nursing activities to minimize disturbances.

Splints have been prescribed for a client who is at risk of developing foot drop following a spinal cord injury. When should the nurse remove and reapply the splints? A. At the client's request B. Each morning and evening C. Every 2 hours D. One hour prior to mobility exercises

C. Every 2 hours

The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action? A. Limit the amount of assistance provided with ADLs. B. Collaborate with the physical therapist and immobilize the client's extremities temporarily. C. Increase the frequency of ROM exercises. D. Educate the client about the importance of frequent position changes.

C. Increase the frequency of ROM exercises.

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client? A. Risk for impaired skin integrity related to immobility and sensory loss B. Impaired physical mobility related to loss of motor function C. Ineffective breathing patterns related to weakness of the intercostal muscles D. Urinary retention related to inability to void spontaneously

C. Ineffective breathing patterns related to weakness of the intercostal muscles

A client is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention? A. Insertion of an intracranial monitoring device B. Treatment with antihypertensives C. Making openings in the skull D. Administration of anticoagulant therapy

C. Making openings in the skull

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension? A. Administer an IV bolus of normal saline prior to repositioning. B. Maintain bed rest until normal BP regulation returns. C. Monitor the client's BP before and during position changes. D. Allow the client to initiate repositioning.

C. Monitor the client's BP before and during position changes.

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI? A. Position the client in a high-Fowler position when in bed. B. Support the knees with a pillow when the client is in bed. C. Perform passive ROM exercises as prescribed. D. Administer NSAIDs as prescribed.

C. Perform passive ROM exercises as prescribed.

The nurse in the intensive care unit (ICU) is using the neurological assessment flow chart to evaluate a calm client with traumatic brain injury (TBI) that has several medications infusing. Which medication would best allow an accurate assessment of the client's neurological status? A. Lorazepam B. Benzodiazepines C. Propofol D. Midazolam

C. Propofol

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect? A. Epidural hemorrhage B. Hypertensive emergency C. Spinal shock D. Hypovolemia

C. Spinal shock

A client sustained a head injury as a result of trauma. The health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures being initiated for this client? A. Antiemetic medications on day three of injury B. Aspiration precautions on day four of injury C. Intubation and ventilator support on day one of injury D. Anticonvulsant medications on day two of injury

D. Anticonvulsant medications on day two of injury

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping? A. Help the family understand that the client could have died. B. Emphasize the importance of accepting the client's new limitations. C. Have the members of the family plan the client's inclient care. D. Assist the family in setting appropriate short-term goals.

D. Assist the family in setting appropriate short-term goals.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event? A. Syncope (fainting) B. Suicide attempts C. Workplace injuries D. Motor vehicle accidents

D. Motor vehicle accidents

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury? A. Restrain the client as ordered. B. Administer opioids PRN as prescribed. C. Arrange for friends and family members to sit with the client. D. Pad the side rails of the client's bed.

D. Pad the side rails of the client's bed.

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy? A. Promoting adequate circulation B. Treating the child's increased ICP C. Assessing secondary brain injury D. Preserving brain homeostasis

D. Preserving brain homeostasis

. A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider? A. Inability to use a wheelchair B. Unable to swallow liquid and solid food C. Incontinent in bowel movements D. Requires full assistance for elimination

D. Requires full assistance for elimination

A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? A. The client reports a headache. B. The client reports pain at the site where the ball hits his head. C. The client is visibly fatigued. D. The client's speech is slightly slurred.

D. The client's speech is slightly slurred.

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event? A. The client received a blood transfusion. B. The client's analgesia regimen was recently changed. C. The client was not repositioned during the night shift. D. The client's urinary catheter became occluded.

D. The client's urinary catheter became occluded.

A concussion results in any loss of consciousness lasting from seconds to minutes.

FALSE

The most common causes of traumatic brain injury are ___________.

Falls

The lowest score of 3 on the Glasgow Coma Scale (GCS) indicates the _____________ responsive level of consciousness.

Least

The most common sites for pressure ulcers, a significant complication of spinal cord injury, are over the ischial tuberosity, the greater trochanter, the _______________, and the occiput.

Sacrum

Autonomic dysreflexia occurs among patients with spinal cord lesions above thoracic vertebra _____________ after spinal shock has subsided.

T6

Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears and nose.

TRUE

Concussion is the condition of temporary loss of neurologic function with no apparent structural damage to the brain.

TRUE

The person with tetraplegia or paraplegia must not remain in any position for longer than 2 hours to prevent the formation of pressure ulcers.

TRUE

Young age, male gender, and alcohol and drug use are risk factors for spinal cord injury.

TRUE