Ch 68

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

"I can apply powder under the liner to help with sweating."

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

Absence of reflexes along with flaccid extremities

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

Motor vehicle crashes

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether:

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

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

1.6

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 intracerebral hematoma

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

Autonomic dysreflexia

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?

Basilar skull fracture

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

Body temperature

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?

Burr holes

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC)

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

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

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?

Irrigates the wound to remove debris

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

Look for signs of increased intracranial pressure

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

Lung auscultation and measurement of vital capacity and tidal volume

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition?

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

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?

Risk for injury

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

Severe TBI.

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

Spasticity

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

Subdural

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

Subdural hematoma

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

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

vomits.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

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?

Suction the airway.

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

Substance abuse Male gender Young age

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

T6

Which of the following is not a manifestation of Cushing's Triad?

Tachycardia

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F

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?

Monitoring is needed as rapid neurologic deterioration may occur.

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.

Motor response Eye opening Verbal response

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Paresthesia

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 Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

coma

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to:

decrease the potential for brain damage.

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

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

30-degree head elevation

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

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

C5

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

Ineffective airway clearance related to brain injury

The nurse is 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

Motor vehicle crashes