Unit 4: SCI + TBI NCLEX RN

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. 1.Fever 2.Seizures 3.Hypoxia 4.Ischemia 5.Hypotension 6.Increased intracranial pressure (ICP)

3,4,5,6 Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury include hypoxia, ischemia, hypotension, and increased ICP that follows primary injury. It does not include fever or seizures.

The nurse is performing an assessment on a child with a head injury. The nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. What should the nurse document that the child is experiencing? 1.Decorticate posturing 2.Decerebrate posturing 3.Flexion of the arms and legs 4.Normal expected positioning after head injury

1 Decorticate posturing is an abnormal flexion of the upper extremities and an extension of the lower extremities with possible plantar flexion of the feet. Decerebrate posturing is an abnormal extension of the upper extremities with internal rotation of the upper arms and wrists and an extension of the lower extremities with some internal rotation.

The nurse walking in a downtown business area witnesses a worker fall from a ladder. The nurse rushes to the victim who is unresponsive. A layperson is attempting to perform resuscitative measures. The nurse should intervene if which action by the layperson is noted? 1.Use of the head tilt-chin lift 2.Checking the scene for safety 3.Use of the jaw thrust maneuver 4.Moving the client away from a busy traffic road

1 Whenever a neck injury is suspected, the jaw thrust maneuver should be used during basic life support (BLS) to open the airway. The head tilt-chin lift produces hyperextension of the neck and could cause complications if a neck injury is present. The scene should be checked for safety, and the client should be moved away from a busy traffic road in order to ensure safety.

The nurse is caring for a child who sustained a head injury after falling from a tree. On assessment of the child, the nurse notes the presence of a watery discharge from the child's nose. The nurse should immediately test the discharge for the presence of which substance? 1.Protein 2.Glucose 3.Neutrophils 4.White blood cells

2 After a head injury, bleeding from the nose or ears necessitates further evaluation. A watery discharge from the nose (rhinorrhea) that tests positive for glucose is likely to be cerebrospinal fluid (CSF) leaking from a skull fracture. On noting watery discharge from the child's nose, the nurse should test the drainage for glucose using an agency-approved reagent strip. If the results are positive, the nurse will contact the primary health care provider. The items in options 1, 3, and 4 are not normally found in mucus.

Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? 1.Headache 2.Blurred vision 3.Elevated temperature 4.Abdominal distention

3 Dantrolene is a centrally acting muscle relaxant. Malignant hyperthermia is a rare but life-threatening adverse effect that can occur with use of this medication. Therefore, an elevated temperature would alert the nurse to this potential adverse effect.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? 1.Obtain a court order for the surgical procedure. 2.Ask the EMS team to sign the informed consent. 3.Transport the victim to the operating room for surgery. 4.Call the police to identify the client and locate the family.

3 In general, there are 2 situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent. Option 1 will delay emergency treatment, and option 2 is inappropriate. Although option 4 may be pursued, it is not the best action because it delays necessary emergency treatment.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? 1.GCS = 3 2.GCS = 6 3.GCS = 9 4.GCS = 11

3 The GCS is a method for assessing neurological status. The highest possible GCS score is 15. A score lower than 8 indicates that coma is present. Motor response points are as follows: Obeys a simple response = 6; Localizes painful stimuli = 5; Normal flexion (withdrawal) = 4; Abnormal flexion (decorticate posturing) = 3; Extensor response (decerebrate posturing) = 2; No motor response to pain = 1. Verbal response points are as follows: Oriented = 5; Confused conversation = 4; Inappropriate words = 3; Responds with incomprehensible sounds = 2; No verbal response = 1. Eye opening points are as follows: Spontaneous = 4; In response to sound = 3; In response to pain = 2; No response, even to painful stimuli = 1. Using the GCS, a score of 3 is given when the client opens the eyes to sound. Localization to pain is scored as 5. When there is no verbal response, the score is 1. The total score is then equal to 9.

A client has suffered a head injury affecting the occipital lobe of the brain. What is the focus of the nurse's immediate assessment? 1.Taste 2.Smell 3.Vision 4.Hearing

3 The occipital lobe is responsible for reception of vision and contains visual association areas. This area of the brain helps the individual to visually recognize and understand the surroundings. The other senses listed are not a function of the occipital lobe.

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? 1.Keeping the client on a stretcher 2.Logrolling the client onto a soft mattress 3.Logrolling the client onto a firm mattress 4.Placing the client on a bed that provides spinal immobilization

4 Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a special bed, such as a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board under it should be used. The remaining options are incorrect and potentially harmful interventions.

The nurse is caring for a client in the emergency department who has sustained a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing that this sequence is compatible with which most likely condition? 1.Concussion 2.Skull fracture 3.Subdural hematoma 4.Epidural hematoma

4 The changes in neurological signs from an epidural hematoma begin with loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebrospinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly

The client with a spinal cord injury at the level of T4 is experiencing a severe throbbing headache with a blood pressure of 180/100 mm Hg. What is the priority nursing intervention? 1.Notify the neurologist. 2.Loosen tight clothing on the client. 3.Place the client in a sitting position. 4.Check the urinary catheter tubing for kinks or obstruction

3 The client is demonstrating clinical manifestations of autonomic dysreflexia, which is a neurological emergency. The first priority is to place the client in a sitting position to prevent hypertensive stroke. Loosening tight clothing and checking the urinary catheter can then be done, and the neurologist can be notified once initial interventions are done.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, the nurse takes the following actions. Arrange the actions in the order they should be performed. All options must be used. 1.Raise the head of the bed. 2.Check for bladder distention. 3.Contact the primary health care provider (PHCP). 4.Loosen tight clothing on the client. 5.Administer an antihypertensive medication. 6.Document the occurrence, treatment, and response.

1,4,2,3,5,6 Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler's position and to remove the noxious stimulus. The nurse would loosen any tight clothing and then check for bladder distention. If the client has a Foley catheter, the nurse would check for kinks in the tubing. The nurse also would check for a fecal impaction and would disimpact the client, if necessary. The PHCP is then contacted, especially if these actions do not relieve the signs and symptoms. Antihypertensive medication may be prescribed by the PHCP to minimize cerebral hypertension. Finally, the nurse documents the occurrence, treatment, and client response.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? 1.Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure 2.Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure 3.Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure 4.Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

2 A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may occur

The client with a traumatic brain injury (TBI) has begun excreting copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the primary health care provider will prescribe which medication? 1.Mannitol 2.Desmopressin 3.Ethacrynic acid 4.Dexamethasone

2 A complication of TBI is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic hormone storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone is usually given to control cerebral edema secondary to brain tumors. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom? 1.Vomiting 2.Minor headache 3.Difficulty speaking 4.Difficulty awakening

2 A concussion after head injury is a temporary loss of consciousness (from a few seconds to a few minutes) without evidence of structural damage. After concussion, the family is taught to monitor the client and call the PHCP or return the client to the emergency department for signs and symptoms such as confusion, difficulty awakening or speaking, one-sided weakness, vomiting, and severe headache. Minor headache is expected.

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? 1.Hyperreflexia 2.Positive reflexes 3.Flaccid paralysis 4.Reflex emptying of the bladder

3 Resolution of spinal shock is occurring when there is return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyper-reflexia rather than flaccidity, and reflex emptying of the bladder.

The nurse witnesses an automobile crash on a highway and stops to provide assistance to the victim. The nurse notes that the client has sustained a head injury and a compound fracture to the left leg. The nurse provides the appropriate care before transport of the victim to the hospital by ambulance. The client develops a severe bone infection at the site of the fracture that requires amputation of the leg and files suit against the nurse who provided care at the scene of the crash. Which is accurate regarding the nurse's immunity from this suit? 1.The Good Samaritan law will protect the nurse. 2.The Good Samaritan law will not protect the nurse. 3.The Good Samaritan law protects laypersons but not professional primary health care providers (PHCPs). 4.The Good Samaritan law will provide immunity from the suit, even if the nurse has accepted compensation for the care provided

1 A Good Samaritan law is passed by a state legislature to encourage nurses and other PHCPs to provide care to a person when an accident, emergency, or injury occurs without fear of being sued for the care provided. Its protection lies in the inability to sue the nurse or other PHCP for negligence in the care provided at the scene of the accident or during the emergency, even if further injury occurred because of the PHCP's care. Called immunity from suit, this protection usually applies only if all conditions of the law are met, such as that the PHCP received no compensation for the care provided and the care given was not willfully and wantonly negligent.

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? 1.Altered breathing pattern 2.Increased likelihood of injury 3.Ineffective oxygen consumption 4.Increased susceptibility to aspiration

1 Altered breathing pattern indicates that the respiratory rate, depth, rhythm, timing, or chest wall movements are insufficient for optimal ventilation of the client. This is a risk for clients with spinal cord injury in the lower cervical area. Ineffective oxygen consumption occurs when oxygenation or carbon dioxide elimination is altered at the alveolar-capillary membrane. Increased susceptibility to aspiration and increased likelihood of injury are unrelated to the subject of the question.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? 1.Elevate the head of the bed. 2.Examine the rectum digitally. 3.Assess the client's blood pressure. 4.Place the client in the prone position

1 Autonomic dysreflexia is a serious complication that can occur in the spinal cord-injured client. Once the syndrome is identified, the nurse elevates the head of the client's bed and then examines the client for the source of noxious stimuli. The nurse also assesses the client's blood pressure, but the initial action would be to elevate the head of the bed. The client would not be placed in the prone position; lying flat will increase the client's blood pressure.

A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement? 1."The medication may make me drowsy." 2."The medication can cause high blood pressure." 3."The medication may cause me to have some muscle pain." 4."The medication may increase my sensitivity to bright light."

1 Baclofen is a central-acting skeletal muscle relaxant useful in treating muscle spasticity, usually in upper motor neuron injury. Side/adverse effects include drowsiness, dizziness, weakness, and nausea. Occasional side effects include headache, paresthesias of the hands and feet, constipation or diarrhea, anorexia, hypotension, confusion, and nasal congestion. The other options are incorrect.

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item? 1.Blood pressure 2.Motor response 3.Pupillary response 4.Level of consciousness

1 Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see if which baseline study has been done? 1.Liver function studies 2.Renal function studies 3.Otoscopic examination 4.Blood glucose measurements

1 Dantrolene is a skeletal muscle relaxant and can cause liver damage; therefore, the nurse should monitor the results of liver function studies. They should be done before therapy starts and periodically throughout therapy. Dantrolene is discontinued if no relief of spasticity is achieved in 6 weeks. The incorrect options are not specifically related to the administration of this medication

A client arrives in the hospital emergency department with a closed head injury to the right side of the head caused by an assault with a baseball bat. The nurse assesses the client neurologically, looking primarily for motor response deficits that involve which area? 1.The left side of the body 2.The right side of the body 3.Both sides of the body equally 4.Cranial nerves only, such as speech and pupillary response

1 Motor responses such as weakness and decreased movement will be seen on the side of the body that is opposite an area of head injury. Contralateral deficits result from compression of the cortex of the brain or the pyramidal tracts. Depending on the severity of the injury, the client may have a variety of neurological deficits

The nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle crash for signs of increased intracranial pressure (ICP). The nurse should assess the child frequently for which early sign of increased ICP? 1.Nausea 2.Papilledema 3.Decerebrate posturing 4.Alterations in pupil size

1 Nausea is an early sign of increased ICP. Late signs of increased ICP include a significant decrease in level of consciousness, Cushing's triad (increased systolic blood pressure and widened pulse pressure, bradycardia, and irregular respirations), and fixed and dilated pupils. Other late signs include decreased motor response to command, decreased sensory response to painful stimuli, posturing, Cheyne-Stokes respirations, and papilledema.

The nurse is reviewing a chart for a child with a head injury. The nurse notes that the level of consciousness has been documented as obtunded. Which finding should the nurse expect to note on assessment of the child? 1.Not easily arousable and limited interaction 2.Loss of the ability to think clearly and rapidly 3.Loss of the ability to recognize place or person 4.Awake, alert, interacting with the environment

1 Obtunded indicates that the child sleeps unless aroused and once aroused has limited interaction with the environment. Confusion indicates that the ability to think clearly and rapidly is lost. Disorientation indicates that the ability to recognize place or person is lost. Full consciousness indicates that the child is alert, awake, oriented, and interacts with the environment.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. 1.Keeping the linens wrinkle-free under the client 2.Preventing unnecessary pressure on the lower limbs 3.Limiting bladder catheterization to once every 12 hours 4.Turning and repositioning the client at least every 2 hours 5.Ensuring that the client has a bowel movement at least once a week

1,2,4 The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catheterization should be done every 4 to 6 hours (catheterization every 12 hours is too infrequent), and urinary catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Ensuring a bowel movement once a week is much too infrequent. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas

The nurse is monitoring ongoing care for a potential organ donor who has been diagnosed with brain death. Which finding indicates to the nurse that the standard for ongoing care has been maintained? 1.PaO2 70 mm Hg 2.Urine output 100 mL/hr 3.Heart rate 52 beats/min 4.Blood pressure 90/48 mm Hg

2 Adequate perfusion must be maintained to all vital organs in order for the client to remain viable as an organ donor. Guidelines may be used to maintain organ viability, but adequate perfusion is necessary. The correct option is the only one that indicates adequate perfusion. The incorrect options identify lower than normal values, thus adequate perfusion would not be maintained.

The nurse is performing an assessment on a client with the diagnosis of Brown-Séquard syndrome. The nurse would expect to note which assessment finding? 1.Bilateral loss of pain and temperature sensation 2.Ipsilateral paralysis and loss of touch and vibration 3.Contralateral paralysis and loss of touch, pressure, and vibration 4.Complete paraplegia or quadriplegia, depending on the level of injury

2 Brown-Séquard syndrome results from hemisection of the spinal cord, resulting in ipsilateral paralysis and loss of touch, pressure, vibration, and proprioception. Contralaterally, pain and temperature sensation are lost because these fibers decussate after entering the cord. The remaining options are not assessment findings in this syndrome.

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? 1.Intracranial pressure changes 2.A long-term sequela of the injury 3.A worsening of the original injury 4.A short-term problem that will resolve in about 1 month

2 Clients with moderate to severe head injury usually have residual physical and cognitive disabilities; these include personality changes, increased fatigue and irritability, mood alterations, and memory changes. The client also may require frequent to constant supervision. The nurse assesses the family's ability to cope and makes appropriate referrals to respite services, support groups, and state or local chapters of the National Head Injury Foundation.

The nurse is admitting a client to the hospital emergency department from a nursing home. The client is unconscious with an apparent frontal head injury. A medical diagnosis of epidural hematoma is suspected. Which question is of the highest priority for the emergency department nurse to ask of the transferring nurse at the nursing home? 1."When did the injury occur?" 2."Was the client awake and talking right after the injury?" 3."What medications has the client received since the fall?" 4."What was the client's level of consciousness before the injury?"

2 Epidural hematomas frequently are characterized by a "lucid interval" that lasts for minutes to hours, during which the client is awake and talking. After this lucid interval, signs and symptoms progress rapidly, with potentially catastrophic intracranial pressure increase. Epidural hematomas are medical emergencies. It is important for the nurse to assist in the differentiation between epidural hematoma and other types of head injuries.

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? 1.Mixed in solution with the IV antibiotics 2.Giving it slowly over 30 to 90 minutes 3.Piggybacked into the packed red blood cells 4.Giving it rapidly over 5 minutes by IV bolus

2 Mannitol is an osmotic diuretic. When used to treat increased ICP, it is given slowly over 30 to 90 minutes, not rapidly and not via IV bolus. Mannitol should not be mixed in solutions with antibiotics, and nothing should be piggybacked with packed red blood cells.

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? 1.Sternal rub 2.Nailbed pressure 3.Pressure on the orbital rim 4.Squeezing of the sternocleidomastoid muscle

2 Nailbed pressure tests a basic motor and sensory peripheral response. Cerebral responses to pain are tested using a sternal rub, placing upward pressure on the orbital rim, or squeezing the clavicle or sternocleidomastoid muscle

A client with a traumatic brain injury is able, with eyes closed, to identify a set of keys placed in his or her hands. On the basis of this assessment finding, the nurse determines that there is appropriate function of which lobe of the brain? 1.Frontal 2.Parietal 3.Occipital 4.Temporal

2 The ability to distinguish an object by touch is called stereognosis, which is a function of the right parietal area. The parietal lobe of the brain is responsible for spatial orientation and awareness of sizes and shapes. The left parietal area is responsible for mathematics and right-left orientation. The other lobes of the brain are not responsible for this function.

The nurse notes that a client who has suffered a brain injury has an adequate heart rate, blood pressure, fluid balance, and body temperature. Based on these clinical findings, the nurse determines that which brain area is functioning properly? 1.Thalamus 2.Hypothalamus 3.Limbic system 4.Reticular activating system

2 The hypothalamus is responsible for autonomic nervous system functions, such as heart rate, blood pressure, temperature, and fluid and electrolyte balance (among others). The thalamus acts as a relay station for sensory and motor information. The limbic system is responsible for emotions. The reticular activating system is responsible for the sleep-wake cycle.

The nurse is assigned to care for an 8-year-old child with a diagnosis of a basilar skull fracture. The nurse reviews the primary health care provider's (PHCP's) prescriptions and should contact the PHCP to question which prescription? 1.Obtain daily weight. 2.Provide clear liquid intake. 3.Nasotracheal suction as needed. 4.Maintain a patent intravenous line

3 A basilar skull fracture is a type of head injury. Nasotracheal suctioning is contraindicated in a child with a basilar skull fracture: Because of the nature of the injury, there is a possibility that the catheter will enter the brain through the fracture, creating a high risk of secondary infection. Fluid balance is monitored closely by daily weight determination, intake and output measurement, and serum osmolality determination to detect early signs of water retention, excessive dehydration, and states of hypertonicity or hypotonicity. The child is maintained on NPO (nothing by mouth) status or restricted to clear liquids until it is determined that vomiting will not occur. An intravenous line is maintained to administer fluids or medications, if necessary.

The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. On assessment of the child, the nurse expects to note which characteristic of this type of posturing? 1.Flaccid paralysis of all extremities 2.Adduction of the arms at the shoulders 3.Rigid extension and pronation of the arms and legs 4.Abnormal flexion of the upper extremities and extension and adduction of the lower extremities

3 Decerebrate (extension) posturing is characterized by the rigid extension and pronation of the arms and legs. Option 1 is incorrect. Options 2 and 4 describe decorticate (flexion) posturing.

A mother arrives at the emergency department with her 5-year-old child and states that the child fell off a bunk bed. A head injury is suspected. The nurse checks the child's airway status and assesses the child for early and late signs of increased intracranial pressure (ICP). Which is a late sign of increased ICP? 1.Nausea 2.Irritability 3.Headache 4.Bradycardia

4 Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain. A head injury can cause bleeding in the brain and result in increased ICP. In a child, early signs include a slight change in level of consciousness, headache, nausea, vomiting, visual disturbances (diplopia), and seizures. Late signs of increased ICP include a significant decrease in level of consciousness, bradycardia, decreased motor and sensory responses, alterations in pupil size and reactivity, posturing, Cheyne-Stokes respirations, and coma.

A client with a traumatic brain injury is on mechanical ventilation. The nurse promotes normal intracranial pressure (ICP) by ensuring that the client's arterial blood gas (ABG) results are within which ranges? 1.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 2.PaO2 60 to 100 mm Hg (60 to 100 mm Hg), PaCo2 30 to 35 mm Hg (30 to 35 mm Hg) 3.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 25 to 30 mm Hg (25 to 30 mm Hg) 4.PaO2 80 to 100 mm Hg (80 to 100 mm Hg), PaCo2 35 to 38 mm Hg (35 to 38 mm Hg)

4 The goal is to maintain the partial pressure of arterial carbon dioxide (PaCo2) at 35 to 38 mm Hg (35 to 38 mm Hg). Carbon dioxide is a very potent vasodilator that can contribute to increases in ICP. The PaO2 is not allowed to fall below 80 mm Hg (80 mm Hg), to prevent cerebral vasodilation from hypoxemia, which can also result in an increase in ICP. Therefore, the remaining options are incorrect.

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? 1.Sufficiently low water content in the stool 2.Low intestinal roughage that promotes easier digestion 3.Constriction of the anal sphincter based on voluntary control 4.Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

4 The principal reflex center for defecation is located in the parasympathetic center at the S1 to S4 level of the spinal cord. This center is most active after the first meal of the day. Other factors that contribute to satisfactory stool passage are sufficient fluid and roughage in the diet and the Valsalva maneuver (which is lost with SCI). During defecation, the anal sphincter relaxes

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? 1.Blowing the nose 2.Isometric exercises 3.Coughing vigorously 4.Exhaling during repositioning

4 Activities that increase intrathoracic and intraabdominal pressures cause an indirect elevation of the intracranial pressure. Some of these activities include isometric exercises, Valsalva's maneuver, coughing, sneezing, and blowing the nose. Exhaling during activities such as repositioning or pulling up in bed opens the glottis, which prevents intrathoracic pressure from rising

A client is admitted to the hospital with a diagnosis of neurogenic shock after a traumatic motor vehicle collision. Which manifestation best characterizes this diagnosis? 1.Bradycardia 2.Hyperthermia 3.Hypoglycemia 4.Increased cardiac output

1 Neurogenic shock can occur after a spinal cord injury. Usually the body attempts to compensate massive vasodilation by becoming tachycardic to increase the amount of blood flow and oxygen delivered to the tissues; however, in neurogenic shock, the sympathetic nervous system is disrupted, so the parasympathetic system takes over, resulting in bradycardia. This insufficient pumping of the heart leads to a decrease in cardiac output. Hypoglycemia is not an indicator of neurogenic shock. Hypothermia develops because of the vasodilation and the inability to control body temperature through vasoconstriction.

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? 1.Updating the home safety sheet 2.Leaving the client in an unchilled area of the room 3.Noting a bowel movement on the client progress note 4.Recording the amount of urine obtained with catheterization

2 The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling. For this reason, the nurse ensures that the client is positioned with no pinching or pressure on paralyzed body parts and that the client will be sufficiently warm.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. 1.Head midline 2.Neck in neutral position 3.Head of bed elevated 30 to 45 degrees 4.Head turned to the side when flat in bed 5.Neck and jaw flexed forward when opening the mouth

1,2,3 Use of proper positions promotes venous drainage from the cranium to keep intracranial pressure from elevating. The head of the client at risk for or with increased intracranial pressure should be positioned so that it is in a neutral, midline position. The head of the bed should be raised to 30 to 45 degrees. The nurse should avoid flexing or extending the client's neck or turning the client's head from side to side

The primary health care provider is planning to administer a skeletal muscle relaxant to a client with a spinal cord injury. The medication will be administered intrathecally. Which medication should the nurse expect to be prescribed and administered by this route? 1.Baclofen 2.Chlorzoxazone 3.Dantrolene sodium 4.Cyclobenzaprine hydrochloride

1 Baclofen is the skeletal muscle relaxant that can be administered intrathecally, which means within the spinal column. Therefore, the remaining options are incorrect.

The nurse is caring for the client who suffered a spinal cord injury 48 hours ago. What should the nurse assess for when monitoring for gastrointestinal complications? 1.A history of diarrhea 2.A flattened abdomen 3.Hyperactive bowel sounds 4.Hematest-positive nasogastric tube drainage

4 Development of a stress ulcer can occur after spinal cord injury and can be detected by Hematest-positive nasogastric tube aspirate or stool. The client is also at risk for paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. A history of diarrhea is irrelevant.

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? 1.Fluid is clear and tests negative for glucose. 2.Fluid is grossly bloody in appearance and has a pH of 6. 3.Fluid clumps together on the dressing and has a pH of 7. 4.Fluid separates into concentric rings and tests positive for glucose.

4 Leakage of cerebrospinal fluid (CSF) from the ears or nose may accompany basilar skull fracture. CSF can be distinguished from other body fluids because the drainage will separate into bloody and yellow concentric rings on dressing material, called a halo sign. The fluid also tests positive for glucose.

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? 1.The intracranial pressure reading is normal. 2.The intracranial pressure reading is elevated. 3.The intracranial pressure reading is borderline. 4.An intracranial pressure reading of 8 mm Hg is low.

1 The normal intracranial pressure is 5 to 15 mm Hg. A pressure of 8 mm Hg is within normal range.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? 1.Take the temperature. 2.Listen to breath sounds. 3.Observe for dyskinesias. 4.Assess extremity muscle strength.

2 Because compromise of respiration is a leading cause of death in cervical cord injury, respiratory assessment is the highest priority. Assessment of temperature and strength can be done after adequate oxygenation is ensured. Because dyskinesias occur in cerebellar disorders, this is not as important a concern as in cord-injured clients unless head injury is suspected.

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? 1.Spinal shock 2.Pulmonary embolism 3.Autonomic dysreflexia 4.Malignant hyperthermia

3 The client with a spinal cord injury is at risk for autonomic dysreflexia with an injury above the level of the seventh thoracic vertebra (T7). Autonomic dysreflexia is characterized by severe, throbbing headache; flushing of the face and neck; bradycardia; and sudden severe hypertension. Other signs include nasal stuffiness, blurred vision, nausea, and sweating. Autonomic dysreflexia is a life-threatening syndrome triggered by a noxious stimulus below the level of the injury. The data in the question are not associated with the conditions noted in the remaining options.

The nurse caring for a child who has sustained a head injury in an automobile crash is monitoring the child for signs of increased intracranial pressure (ICP). For which early sign of increased ICP should the nurse monitor? 1.Increased systolic blood pressure 2.Abnormal posturing of extremities 3.Significant widening pulse pressure 4.Changes in level of consciousness

4 An altered level of consciousness is an early sign of increased intracranial pressure (ICP). Late signs of increased ICP include tachycardia leading to bradycardia, apnea, systolic hypertension, widening pulse pressure, and posturing.

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? 1.Take and record vital signs every 4 to 8 hours. 2.Prophylactically hyperventilate during the first 24 hours. 3.Treat a central fever with the administration of antipyretic medications such as acetaminophen. 4.Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

4 Avoiding extreme flexion and extension of the neck can enhance venous drainage and help prevent increased intracranial pressure. As a general rule, hyperventilation is avoided during the first 24 hours postoperatively because it may produce ischemia caused by cerebral vasoconstriction. Vital signs need to be taken and recorded at least every 1 to 2 hours. Central fevers caused by hypothalamic damage respond better to cooling (hypothermia blankets, sponge baths) than to the administration of antipyretic medications.

Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing a side or adverse effect of the medication if which is noted? 1.Dizziness 2.Drowsiness 3.Abdominal pain 4.Lightheadedness

3 Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise. The nurse notifies the primary health care provider if these occur. The signs and symptoms in the remaining options are expected side effects due to the central nervous system-depressant effects of the medication.

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? 1.Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. 2.The client has compulsive habits that should be ignored as long as they are not harmful. 3.The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. 4.Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

4 Depression frequently may be seen in the client with spinal cord injury and may be exhibited as a loss of appetite. However, the client should be allowed to choose the types of food eaten and when they are eaten as much as is feasible because it is one of the few areas of control that the client has left. There is no information in the question that would indicate that the client is anorexic or obsessive-compulsive or has a slow metabolism.

The nurse is assigned to care for a child with a brain injury who has a temporal lobe herniation and increasing intracranial pressure. Which signs should the nurse identify as indicative of this type of injury? Select all that apply. 1.Flaccid paralysis 2.Pupil response to light 3.Ipsilateral pupil dilation 4.Compression of the sixth cranial nerve 5.Shifting of the temporal lobe laterally across the tentorial notch

1,3,5 Temporal lobe herniation or uncal herniation refers to a shifting of the temporal lobe laterally across the tentorial notch. This produces compression of the third cranial nerve and ipsilateral pupil dilation. If pressure continues to rise, flaccid paralysis, pupil fixation, and death will result

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? 1.Assessing lung sounds 2.Monitoring temperature 3.Administering intravenous (IV) fluids 4.Performing range-of-motion exercises to the extremities

3 Perfusion to the kidney is affected by blood pressure, which in turn is affected by blood vessel tone and fluid volume. Therefore, the client who was previously dehydrated with medications to control intracranial pressure is now in need of rehydration to maintain perfusion to the kidneys. The nurse should prepare to infuse IV fluids as prescribed and continue to monitor urine output. The remaining options will not maintain viability of the kidneys.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? 1.Ask the family to deliver the care. 2.Leave the client alone until ready to participate. 3.Advise the client that rehabilitation progresses more quickly with cooperation. 4.Acknowledge the client's anger and continue to encourage participation in care.

4 Adjusting to paralysis is physically and psychosocially difficult for the client and family. The nurse recognizes that the client goes through the grieving process in adjusting to the loss and may move back and forth among the stages of grief. The nurse acknowledges the client's feelings while continuing to meet the client's physical needs and encouraging independence. The family also is in crisis and needs the nurse's support and should not be relied on to provide care. The nurse cannot simply neglect the client until the client is ready to participate. Option 3 represents a factual but noncaring approach to the client and is not therapeutic.

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? 1.Return of spinal shock 2.Malignant hypertension 3.Impending brain attack (stroke) 4.Autonomic dysreflexia (hyperreflexia)

4 Autonomic dysreflexia (hyperreflexia) results from sudden strong discharge of the sympathetic nervous system in response to a noxious stimulus. Signs and symptoms include pounding headache, nausea, nasal stuffiness, flushed skin, piloerection, and diaphoresis. Severe hypertension can occur, with a systolic BP rising potentially as high as 300 mm Hg. It often is triggered by thermal or mechanical events such as a kinking of catheter tubing, constipation, urinary tract infection, or any variety of cutaneous stimuli. The nurse must recognize this situation immediately and take corrective action to remove the stimulus. If untreated, this medical emergency could result in stroke, status epilepticus, or possibly death.

The client with a cervical spine injury has cervical tongs applied in the emergency department. What should the nurse include when planning care for this client? Select all that apply. 1.Using a RotoRest bed 2.Ensuring that weights hang freely 3.Removing the weights to reposition the client 4.Assessing the integrity of the weights and pulleys 5.Comparing the amount of prescribed traction with the amount in use

1,2,4,5 Cervical tongs are applied after drilling holes in the client's skull under local anesthesia. Weights are attached to the tongs, which exert pulling pressure on the longitudinal axis of the cervical spine. Serial x-rays of the cervical spine are taken, with weights being added gradually until the x-ray reveals that the vertebral column is realigned. After that, weights may be reduced gradually to a point that maintains alignment. The client with cervical tongs is placed on a Stryker frame or RotoRest bed. The nurse ensures that weights hang freely and the amount of weight matches the current prescription. The nurse also inspects the integrity and position of the ropes and pulleys. The nurse does not remove the weights to administer care.

Which interventions would be included in the care of a client with a head injury and a subarachnoid bolt? Select all that apply. 1.Monitor vital signs. 2.Monitor neurological status. 3.Monitor the dressing for signs of infection. 4.Monitor for signs of increased intracranial pressure. 5.Drain cerebrospinal fluid when the intracranial pressure is elevated.

1,2,3,4 A subarachnoid bolt is inserted into the subarachnoid space and is used to measure intracranial pressure. Because a subarachnoid bolt is placed in the subarachnoid space, it is not capable of draining cerebrospinal fluid, which is produced in the ventricles. Therefore, the option to drain cerebrospinal fluid is not an intervention. The remaining options are appropriate interventions

The nurse is caring for a child with a head injury. The nurse observes decerebrate posturing. What is the nurse's best action? 1.Document the finding. 2.Complete a head-to-toe examination. 3.Notify the primary health care provider. 4.Inform the family of the improved status.

3 Decorticate posturing indicates a lesion in the cerebral hemisphere or disruption of the corticospinal tracts. Decerebrate posturing indicates damage in the diencephalon, midbrain, or pons. The progression from flexion to extension posturing usually indicates deteriorating neurological function, not improvement, and warrants primary health care provider notification. A focused neurological examination is priority at this time, not a complete head to toe.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? 1.Insert nasal packing. 2.Document the findings. 3.Contact the primary health care provider (PHCP). 4.Monitor the client's blood pressure and check for signs of increased intracranial pressure

3 Bloody or clear drainage from either the nasal or the auditory canal after head trauma could indicate a cerebrospinal fluid leak. The appropriate nursing action is to notify the PHCP because this finding requires immediate intervention. The remaining options are inappropriate nursing actions in this situation

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? 1.A psychologist 2.A social worker 3.A neuropsychologist 4.A vocational rehabilitation specialist

3 Clients with cognitive deficits after head injury may benefit from referral to a neuropsychologist who specializes in evaluating and treating cognitive problems. The neuropsychologist plans an individual program of therapy and initiates counseling to help the client reach maximal potential. The neuropsychologist works in collaboration with other disciplines that are involved in the client's care and rehabilitation. The remaining options are incorrect because these health care workers do not specialize in evaluating and treating cognitive problems.

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. 1.Reduced ICP 2.Increased diuresis 3.Increased osmotic pressure of glomerular filtrate 4.Reduced tubular reabsorption of water and solutes 5.Reabsorption of sodium and water in the loop of Henle

1,2,3,4 Mannitol is an osmotic diuretic that induces diuresis by raising the osmotic pressure of glomerular filtrate, thereby inhibiting tubular reabsorption of water and solutes. It is used to reduce intracranial pressure in the client with head trauma. The incorrect option would cause fluid retention through reabsorption, thereby increasing ICP

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? 1."I will use a straw for drinking." 2."I will drive only during the daytime." 3."I will be careful because the device alters balance." 4.I will wash the skin daily under the lamb's wool liner of the vest.

2 The halo device alters balance and can cause fatigue because of its weight. The client should cleanse the skin daily under the vest to protect the skin from ulceration and should avoid the use of powder or lotions. The liner should be changed if odor becomes a problem. The client should have food cut into small pieces to facilitate chewing and use a straw for drinking. Pin care is done as instructed. The client cannot drive at all, because the device impairs the range of vision.