Adaptive Quizzes Chapter 68 Neuro Trauma

- allodynia Allodynia is a type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus

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

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

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.

- dehydrate the brain and reduce cerebral edema. Osmotic diuretics draw water across intact membranes, thereby reducing the volume of brain and extracellular fluid.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to - control fever. - control shivering. - dehydrate the brain and reduce cerebral edema. - reduce cellular metabolic demand.

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

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. Bradycardia Hypertension Bradypnea Hypotension Tachycardia

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

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

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

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as - coma. - minimally responsive. - least responsive. - most responsive.

- 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.

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

- supine position with the head slightly elevated. After surgery, the nurse should place the client in either a supine position with the head slightly elevated or a side-lying position on the unaffected side. The dorsal recumbent, Trendelenburg, and prone positions can increase intracranial pressure.

The nurse is caring for a client immediately after supratentorial intracranial surgery. The nurse performs the appropriate action by placing the patient in the - dorsal recumbent position. - supine position with the head slightly elevated. - prone position with the head turned to the unaffected side. - Trendelenburg position.

- Lethargy and stupor As ICP increases, the patient becomes stuporous, reacting only to loud or painful stimuli. At this stage, serious impairment of brain circulation is probably taking place, and immediate intervention is required.

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? - A bounding pulse - Bradycardia - Hypertension - Lethargy and stupor

- 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. Options A, B, and C are not the most important parameters to monitor.

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

- 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.

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

Absence of reflexes along with flaccid extremities

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

- Restricting fluid intake and hydration Fluid restriction may be necessary if the client develops cerebral edema and hypervolemia from SIADH.

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? - Maintaining adequate hydration - Administering prescribed antipyretics - Restricting fluid intake and hydration - Hyperoxygenation before and after tracheal suctioning

- Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? - Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. - Contusions are deep brain injuries. - Contusions are microscopic brain injuries. - Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

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

A 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.

- Paresthesia When a client reports numbness and tingling in an area, he is reporting a paresthesia.

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

- 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.

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

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

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

- Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.

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

- Alteration in level of consciousness (LOC) The first sign of possible subdural hematoma is a change in LOC. Speech may be affected later as the client experiences continued reduction in oxygenation. Bradycardia and a decreased heart rate occur later if the condition isn't treated.

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? - Decreased heart rate - Bradycardia - Alteration in level of consciousness (LOC) - Slurred speech

- 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 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

- 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 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.

- Suction the airway. Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions.

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. - Maintain a patent airway. - Suction the airway.

- carefully move the client to a flat surface and turn him on his side. When caring for a client experiencing a tonic-clonic seizure, the nurse should help the client to a flat nonelevated surface and then position him on his side to ensure that he doesn't aspirate and to protect him from injury. These steps help reduce the risk of injury from falling or hitting surrounding objects and help establish an open airway. The client shouldn't be restrained during the seizure. Also, nothing should be placed in his mouth; anything in the mouth could impair ventilation and damage the inside of the mouth.

A client is sitting in a chair and begins having a tonic-clonic seizure. The most appropriate nursing response is to: - hold the client's arm still to keep him from hitting anything. - carefully move the client to a flat surface and turn him on his side. - allow the client to remain in the chair but move all objects out of his way. - place an oral airway in the client's mouth to maintain an open airway.

unequal response In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated.

A nurse is assessing a client who has been in a motor vehicle collision. The client directly and accurately answers questions. The nurse notes a contusion to the client's forehead; the client reports a headache. Assessing the client's pupils, what reaction would confirm increasing intracranial pressure? unequal response equal response rapid response constricted response

- C5 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion.

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

Eye opening Verbal response Motor response

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

- Increased intracranial pressure (ICP) When ICP increases, Cushing triad may develop, which involves decreased heart and respiratory rates and increased systolic blood pressure.

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication? - Shock - Encephalitis - Increased intracranial pressure (ICP) -Status epilepticus

- An area of bruising over the mastoid bone Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle sign). Basilar skull fractures are suspected when cerebrospinal fluis (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe 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