Chapter 63: Management of Patients with Neurologic Trauma

Which Glasgow Coma Scale score is indicative of a severe head injury? 7 9 11 13

7 A score between 3 and 8 is generally accepted as indicating a severe head injury.

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

severe hypertension, slow heart rate, pounding headache, sweating Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

The earliest sign of serious impairment of brain circulation related to increased ICP is: A change in consciousness. Hypertension. Bradycardia. A bounding pulse.

A change in consciousness. The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Absence of reflexes along with flaccid extremities Positive Babinski's reflex along with spastic extremities Hyperreflexia along with spastic extremities Spasticity of all four extremities

Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation? Escape of cerebrospinal fluid from the client's ear An area of bruising over the mastoid bone Escape of cerebrospinal fluid from the client's nose A bloodstain surrounded by a yellowish stain on the head dressing

An area of bruising over the mastoid bone Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? Elevate patient's head or follow the physician's directive for body position. Assist the patient with frequent ambulation. Apply elastic stockings to lower extremities. Take care not to jar the bed or cause unnecessary activity.

Apply elastic stockings to lower extremities. To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Orthostatic hypotension Autonomic dysreflexia Spinal shock Thrombophlebitis

Autonomic dysreflexia Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

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? Frontal skull fracture Occipital skull fracture Temporal skull fracture Basilar skull fracture

Basilar skull fracture A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

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

C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

At which of the following spinal cord injury levels does the patient have full head and neck control? C3 C5 C2 C4

C5 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? Seizures Change in level of consciousness (LOC) Pupil changes Restlessness

Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.

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? Decorticate Decerebrate Normal Flaccid

Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

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? Drainage of cerebrospinal fluid from the ears Bruising under the eyes Drainage of cerebrospinal fluid from the nose Ecchymosis over the mastoid

Ecchymosis over the mastoid With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

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: Absence of brain stem reflexes Coma Apnea Glasgow Coma Scale of 6

Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? Grade 1 concussion Grade 2 concussion Grade 3 concussion Grade 4 concussion

Grade 3 concussion There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes

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

Irrigates the wound to remove debris Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

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). Cluster all procedures together. Avoid sedation. Keep the head of the client's bed flat.

Keep the client's neck in a neutral position (no flexing). To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).

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: An epidural hematoma Leakage of cerebrospinal fluid (CSF) Increasing intracranial pressure (ICP) Meningitis

Leakage of cerebrospinal fluid (CSF) In patients with a skull fracture, a halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. This finding is not specifically indicative of meningitis, increased ICP or an epidural hematoma.

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

Look for signs of increased intracranial pressure The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Bleeding continues into the intracerebral area. Symptoms will evolve over a period of 1 week.

Monitoring is needed as rapid neurologic deterioration may occur. The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

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

Raise the head of the bed and place the patient in a sitting position. The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

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 Dressing or grooming self-care deficit Disturbed sensory perception (visual) Impaired verbal communication

Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.

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

Subdural hematoma A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T10 L4 T6 S2

T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

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? Assess for pupillary response frequently. Assess vital signs frequently. Take daily weights. Reposition the client frequently.

Take daily weights. A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? Turning frame Traction with weights and pulleys Cast Cervical collar

Traction with weights and pulleys Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Decreased body temperature Increased pulse Increased respirations Widened pulse pressure

Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

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? intracerebral chronic subacute acute

acute Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain? hyperalgesia idiopathic nociceptive allodynia

allodynia Allodynia is a type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus. Hyperalgesia is a type of neurogenic pain whereby clients experience an increased response to a painful stimulus. Nociceptive pain is detected by specialized sensory nerves located throughout the soft tissues and is not neurogenic. Idiopathic pain has no apparent underlying cause and is not neurogenic.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care? client maintains mechanical ventilation with minimal mucus accumulation client's skin remains clean, dry, and intact client reports no discomfort client regains bowel elimination capacity

client maintains mechanical ventilation with minimal mucus accumulation A client with a lumbar spinal injury would not require mechanical ventilation.

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. minimally responsive. least responsive. most responsive.

coma. The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: payment status will change if the client isn't sedated. nutritional protocol will be effective after the client sedation therapy is tapered. to continue IV administration of other scheduled medications. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Autonomic dysreflexia Areflexia Tetraplegia Paraplegia

Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

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 occur when the brain is jarred and bounces off the skull on the opposite side from the blow. Contusions are microscopic brain injuries. Contusions are deep brain injuries. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF? Assess for crepitus around the nose Assess for bloody drainage Assess for a halo sign Assess for a wing sign

Assess for a halo sign Most clients are hospitalized for at least 24 hours after a significant head injury. The nurse examines the client to identify signs of head trauma and tests drainage from the nose or ear. To detect any CSF drainage, the nurse looks for a halo sign, which is a blood stain surrounded by a clear or yellowish stain. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.

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

Body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

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. Tachycardia Bradycardia Bradypnea Hypertension Hypotension

Bradycardia Bradypnea Hypertension The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

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? Insertion of Crutchfield tongs Application of Halo traction Hypophysectomy Burr holes

Burr holes An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Subdural Cerebral Epidural Intracerebral

Subdural A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first? The client with a concussion The client with a basilar fracture The client with an open head injury The client with a coup injury

The client with a basilar fracture Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do? Apply antiembolic stockings. Lay the client flat. Place the client in a sitting position. Notify the physician.

Place the client in a sitting position. The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply. Widened pulse pressure Increased cerebral perfusion Lowered systolic blood pressure Slow bounding pulse Respiratory irregularities

Widened pulse pressure Slow bounding pulse Respiratory irregularities In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure, with a widening of the pulse pressure and cardiac slowing.

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. Apnea No brain waves Absence of brainstem reflexes Coma

Absence of brainstem reflexes Coma Apnea The three cardinal signs of brain death on clinical examination are coma, the absence of brain stem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brain stem auditory evoked potential, are often used to confirm brain death.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? To prevent secondary brain injury So that the patient will not have a respiratory arrest To increase cerebral perfusion pressure Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

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

Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

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

Insertion of a nasogastric (NG) tube Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

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 Administer enemas, as needed Position the client in the supine position Restrain the client, as indicated

Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered

Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.

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. Motor response Verbal response Muscle strength Eye opening Intelligence

Motor response Verbal response Eye opening LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Falls Acts of violence Sports-related injuries Motor vehicle crashes

Motor vehicle crashes The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

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

Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

While snowboarding, a client 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? concussion laceration contusion skull fracture

concussion A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: decrease the potential for brain damage. prevent embolism. assess for infection. follow hospital protocol.

decrease the potential for brain damage. It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? Diffuse axonal injury Intracranial hemorrhage Concussion Contusion

Contusion Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. Drug abuse Alcohol use Female gender European American ethnicity Young age

Drug abuse Alcohol use Young age The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.

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

Herniation Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? Risk for injury related to neurologic deficit Impaired verbal communication related to confusion Feeding self-care deficit related to neurologic trauma Disturbed sensory perception (visual) related to neurologic trauma

Risk for injury related to neurologic deficit Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.

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 vomits. reports a headache. sleeps for short periods of time. reports generalized weakness.

vomits. Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.