Chapter 63: Management of Patients with Neurologic Trauma - PrepU

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). -Avoid sedation. -Cluster all procedures together. -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).

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

The nurse anticipates that the client has developed chronic subdural hematoma stroke and that computed tomography (CT) imaging of the brain will be ordered. This client has had a prior head trauma with a negative imaging scan. Prior head trauma can lead to the development of a chronic subdural hematoma, which presents with symptoms such as severe headache, mental deterioration, focal neurologic changes, personality changes, and/or symptoms that the client is having a stroke. There is no indication that the client had follow-up imaging based on the prior head trauma, which should be included in protocol management of head injuries. Prior head trauma can lead to the development of a chronic subdural hematoma. Based on the clinical presentation of a severe headache, this is the most likely clinical diagnosis. Based on the clinical presentation, follow-up imaging is indicated to confirm the presence of a chronic subdural hematoma, which can occur following a recent head trauma. Because the head trauma occurred a few months ago, an acute finding would have presented earlier, at the time of injury. The differential diagnosis of chronic subdural hematoma includes a stroke but there is insufficient clinical evidence to support this finding. An electrocardiogram (ECG) is not indicated at this time because there is no provided clinical evidence of any cardiac abnormalities. Coagulation studies are not indicated at this time because the priority is to obtain an imaging study.

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 -Intelligence -Muscle strength

-Eye opening -Verbal response -Motor response 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.

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? -6 to 8 hours -18 to 36 hours -12 to 24 hours -48 to 72 hours

18 to 36 hours Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

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.

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 -Thrombophlebitis -Orthostatic hypotension -Spinal shock

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.

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? -Decerebrate -Normal -Flaccid -Decorticate

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.

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? -Tachycardia -Widening pulse pressure -Hypertension -Irregular respiration

Tachycardia Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders? -The second cervical vertebrae -The first thoracic vertebrae -The seventh thoracic vertebrae -The first lumbar vertebrae

The first thoracic vertebrae Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.

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

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? -An epidural hematoma -An extradural hematoma -An intracerebral hematoma -A subdural hematoma

An intracerebral hematoma Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

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 -Urine testing for acetone -Serum sodium concentration testing -Out of bed to the chair three times a day

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.

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 -Administers an oral analgesic for pain -Administers acetaminophen (Tylenol) for headache -Shaves the hair around the wound

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 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 is the only device that can be applied for stabilization of a spinal fracture. -It allows for stabilization of the cervical spine along with early ambulation. -It is less bulky and traumatizing for the patient to use. -The patient can remove it as needed.

It allows for stabilization of the cervical spine along with early ambulation. Halo devices provide immobilization of the cervical spine while allowing early ambulation.

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

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.

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

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

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 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? -Cervical collar -Cast -Traction with weights and pulleys -Turning frame

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.

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? -A bloodstain surrounded by a yellowish stain on the head dressing -Escape of cerebrospinal fluid from the client's ear -Escape of cerebrospinal fluid from the client's nose -An area of bruising over the mastoid bone

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.

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

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.

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.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? -Maintain a diet for the client that is high in protein, vitamins, and calories. -Avoid range of motion exercises for the client because of spasms. -Keep accurate intake and output. -Watch closely for signs of urinary tract infection.

Maintain a diet for the client that is high in protein, vitamins, and calories. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

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: -Mild TBI. -Brain death. -Moderate TBI. -Severe TBI.

Severe TBI. A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

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

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? -subacute -acute -intracerebral -chronic

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 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? -Sciatic nerve pain -Herniation -Paresthesia -Paralysis

Paresthesia When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

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

Spinal shock Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? -Slight headache -Rapid heart rate -Sweating -Runny nose

Sweating Characteristics of this acute emergency are as follows: severe hypertension; slow heart rate; pounding headache; nausea; blurred vision; flushed skin; sweating; goosebumps (erection of pilomotor muscles in the skin); nasal stuffiness; and anxiety.

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? -Continuous use of an indwelling catheter -Meticulous cleanliness -Avoidance of all lotions and lubricants -Allowing the client to choose the position of comfort

Meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough? -Administer oxygen as prescribed. -Use mechanical ventilation. -Let the airway stay as it currently is. -Suction the airway.

Suction the airway. Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.

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: -Coma -Absence of brain stem reflexes -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.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? -Intracerebral -Diffuse axonal -Subdural -Epidural

Epidural An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.

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)? -Position the client in the supine position -Maintain cerebral perfusion pressure from 50 to 70 mm Hg -Restrain the client, as indicated -Administer enemas, as needed

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

Subdural hematoma A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the 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.

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 client has ecchymosis in the periorbital region. -The client has an elevated temperature. -The client has serous drainage from the nose.

The client has cerebral spinal fluid (CSF) leaking from the ear Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? -It results from inadequate delivery of nutrients and oxygen to the cells. -It refers to the difficulties suffered by the client and family related to the changes in the client. -It results from initial damage to the brain from the traumatic event. -It refers to the permanent deficits seen after the rehabilitation process.

It results from initial damage to the brain from the traumatic event. The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.

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? -Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. -Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. -Reassure the client that a headache is expected and will go away without treatment. -Notify the physician; a headache is an early sign of worsening neurologic status.

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? -"They help stabilize total body functioning." -"They help prevent the development of contractures." -"They aid in restoring your skeletal integrity." -"They prepare you to function in the absence of your leg function."

"They help prevent the development of contractures." Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? -Trendelenburg's -30-degree head elevation -Flat -Side-lying

30-degree head elevation For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.

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 -Bruising under the eyes -Drainage of cerebrospinal fluid from the nose -Drainage of cerebrospinal fluid from the ears

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 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 -Emphasize complete bed rest -Look for signs of increased intracranial pressure -Look for a halo sign

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 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. -nuchal rigidity and Kernig's sign. -motor loss in the legs that exceeds that in the arms. -pupillary changes.

raccoon's eyes and Battle sign. A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

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. -Call the physician. -Assess the patient for a full bladder. -Assess the patient for a fecal impaction.

Place the patient in a sitting position. Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in normal people. It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis (most often of the forehead), nausea, nasal congestion, and bradycardia. It occurs among patients with cord lesions above T6 (the sympathetic visceral outflow level) after spinal shock has subsided (Bader & Littlejohns, 2010). The patient is placed immediately in a sitting position to lower blood pressure.

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? -Rebound hypotension -Rebound hypertension -Urinary tract infection -Spinal shock

Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.