chapter 68- management of patients with neurologic trauma

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? Establishing an intermittent catheterization routine every 4 hours Managing spasticity with range-of-motion exercises and medications Establishing an ambulation program using short leg braces Preventing autonomic dysreflexia by preventing bowel impaction

Establishing an intermittent catheterization routine every 4 hours-

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury

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

Insertion of a nasogastric (NG) tube

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 results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process. 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-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.

The nurse received the report from a previous shift. One of her clients 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-

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

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

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

Young age Alcohol use Drug abuse

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? Concussion Autonomic dysreflexia Spinal shock Contusion

Autonomic dysreflexia-

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 will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating."- it can contribute to the development of pressure ulcers

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. Moderate TBI. Severe TBI. Brain death.

severe TBI

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 An area of bruising over the mastoid bone 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- battle sign can indicate fracture

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.

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

C5- 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.

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- Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness

The most important nursing priority of treatment for a patient with an altered LOC is to: Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. Maintain a clear airway to ensure adequate ventilation. Position the patient to prevent injury and ensure dignity.

Maintain a clear airway to ensure adequate ventilation.

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation Ensuring that the patient regains full brain function

Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation

Which signs are considered cardinal signs of brain death? Select all that apply. Absence of brainstem reflexes No brain waves Apnea Coma

absence of brainstem reflexes, apnea, coma

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? Simple Comminuted Depressed Basilar

basilar

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

basilar skull fracture

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- hyperthermia increases brain metabolism, increasing the potential for brain damage

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as coma. a need for emergency attention. least responsive. most responsive.

coma-score of 7 or less is generally interpreted as coma. A GCS score of 10 or less indicates a need for emergency attention. A GCS score of 3 is interpreted as least responsive; a score of 15 is interpreted as most responsive.

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- results from a blow to the head that jars the brain

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

risk for injury-

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- result of lesions at the midbrain and is more ominous than decorticate posturing, patient has no motor function, is limp, and lacks motor tone with flaccid posturing

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

spasticity- associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes

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

subdural hematoma- collection of blood between the dura mater and the brain

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

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

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- in addition they can elevate the bed, maintain the clients head and neck in neutral alignment, initiate measures to prevent valsalva maneurver, maintain body temp, administer O2

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

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? Lower back pain Burning sensation on urination Frequency of urination Fever and change in urine clarity

fever and change in urine clarity-

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

intracerebral hematoma- is bleeding within the brain, into the parenchyma of the brain

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 Sports-related injuries Motor vehicle crashes Acts of violence

motor vehicle crashes-

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Radiography Myelography Neurologic examination Computed tomography (CT) scan

neurologic examination- reveals the level of the spinal cord 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

paresthesia-

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 large volume enema Digital stimulation Bowel surgery

Insertion of a nasogastric tube-to relieve distention and to prevent vomiting and aspiration.

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- cast and a cervical collar are used to immobilize the injured portion of the spine

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

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.-

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

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. nutritional protocol will be effective after the client sedation therapy is tapered. to continue IV administration of other scheduled medications. payment status will change if the client isn't sedated.

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

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- associated with SCI reflects sudden depression reflex activity in the spinal cord below the level of injury

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

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

take daily weights- indicate possible fluid imbalance

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.

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? Symptoms will evolve over a period of 1 week. Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Bleeding continues into the intracerebral area.

Monitoring is needed as rapid neurologic deterioration may occur

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

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

Risk for injury related to neurologic deficit

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- bruising over the mastoid also called a battle sign

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-

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 chronic subacute intracerebral

acute

A client is being admitted to a rehabilitation hospital as a result of the tetraplegia caused a stroke. The client's condition is stable, and after admission the client will begin physical and psychological therapy. An important part of nursing management is to reposition the client every 2 hours. What is the rationale behind this intervention? maintain sufficient integument capillary pressure provide a change of scenery maintain psychological well-being passive exercise

maintain sufficient integument capillary pressure-