Chapter 63: Management of Patients with Neurologic Trauma

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

Absence of reflexes along with flaccid extremities

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 paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?

"They help prevent the development of contractures."

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

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

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak?

18 to 36 hours

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes?

30-degree head elevation

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80

The earliest sign of serious impairment of brain circulation related to increased ICP is:

A change in consciousness.

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Alcohol use Drug abuse Young age

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?

An area of bruising over the mastoid bone

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolic stockings prior to elevation of the head.

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

Apply elastic stockings to lower extremities.

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?

Autonomic dysreflexia

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of?

Autonomic dysreflexia

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

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except?

Being an athlete

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

Body temperature

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

Body temperature

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.

Bradycardia Hypertension Bradypnea

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

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

C5

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

Contusion

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.

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 evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

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?

Epidural hematoma

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 with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

Fever and change in urine clarity

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:

Glasgow Coma Scale of 6

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action?

Immediate craniotomy

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

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

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?

Insertion of a nasogastric 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 patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

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

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?

Meticulous cleanliness

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurologic examination

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 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?

Place the client in a sitting position.

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

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?

Raise the head of the bed and place the patient in a sitting position.

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

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

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

Severe TBI.

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

Spasticity

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal shock

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

Subdural

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

Subdural hematoma

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

T6

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

Tachycardia

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of arginine vasopressin deficiency (AVP-D). Which of the following would be an appropriate nursing intervention to monitor for early signs of AVP-D?

Take daily weights.

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 intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first?

The client with a basilar fracture

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

The Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client?

They have the beginning of a pressure sore.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened pulse pressure

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?

acute

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 ________and that _________will be ordered.

chronic subdural hematoma computed tomography (CT) imaging of the brain

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.

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

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:

famotidine (Pepcid).

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign.

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

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:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

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.