Chapter 63: Management of Patients with Neurologic Trauma

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?

"I can apply powder under the liner to help with sweating."

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

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?

Basilar

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

Body temperature

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

Ecchymosis over the mastoid

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a nasogastric (NG) tube

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?

Irrigates the wound to remove debris

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

Keep the client's neck in a neutral position (no flexing).

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)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

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?

Temperature increase from 98.0°F to 99.6°F

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear.

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results.

The nurse anticipates that the client has developed: chronic subdural hematoma stroke and that CT will be ordered

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

Venous pooling in the extremities Bradycardia Warm skin

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply.

Eye opening Verbal response Motor response

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?

Paresthesia

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

Young age Male gender Substance abuse

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue