Ch. 68: Mgmt of Pts w/ Neurologic Trauma
Which Glasgow Coma Scale score is indicative of a severe head injury? 7 9 11 13
Correct response: 7 Explanation: A score between 3 and 8 is generally accepted as indicating a severe head injury.
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 A subdural hematoma An extradural hematoma An intracerebral hematoma
Correct response: An intracerebral hematoma Explanation: Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.
Which of the following is not a manifestation of Cushing's Triad? Bradycardia Bradypnea Hypertension Tachycardia
Correct response: Tachycardia Explanation: Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
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? Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air Temperature increase from 98.0°F to 99.6°F
Correct response: Temperature increase from 98.0°F to 99.6°F Explanation: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
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? chronic acute subacute intracerebral
Correct response: acute Explanation: 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.
While snowboarding, a 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? laceration contusion concussion skull fracture
Correct response: concussion Explanation: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.
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? Insertion of Crutchfield tongs Burr holes Hypophysectomy Application of Halo traction
Correct response: Burr holes Explanation: An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
At which of the following spinal cord injury levels does the patient have full head and neck control? C2 C3 C5 C4
Correct response: C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At 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.
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
Correct response: Decerebrate Explanation: 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.
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. Intelligence Muscle strength Motor response Eye opening Verbal response
Correct response: Eye opening Verbal response Motor response Explanation: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: Coma Glasgow Coma Scale of 6 Apnea Absence of brain stem reflexes
Correct response: Glasgow Coma Scale of 6 Explanation: The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.
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 Look for a halo sign Emphasize complete bed rest Look for signs of increased intracranial pressure
Correct response: Look for signs of increased intracranial pressure Explanation: The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.
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 Acts of violence Falls Motor vehicle crashes Sports-related injuries
Correct response: Motor vehicle crashes Explanation: The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.
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? Herniation Paresthesia Sciatic nerve pain Paralysis
Correct response: Paresthesia Explanation: When a client reports numbness and tingling in an area, he is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? Reassure them that progress will be made, but it takes time. Provide factual information and emotional support. Allow family members distance and space to deal with the changes to the client. Wait for the family members to approach with questions.
Correct response: Provide factual information and emotional support. Explanation: During the most acute phase of injury, family memebers need factual information and support from the health care team. Allowing distance and space can alienate the family, and make them feel like they are not involved with the client. The family may be unsure of approaching the nurse and may not know what questions to ask. The nurse should be available and offer information to start. He or she should not provide false reassurance; they need factual information at this time.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? S2 T6 L4 T10
Correct response: T6 Explanation: 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.
Which are risk factors for spinal cord injury (SCI)? Select all that apply. Alcohol use Drug abuse Female gender Caucasian ethnicity Young age
Correct response: Young age Alcohol use Drug abuse Explanation: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.
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 sleeps for short periods of time. reports generalized weakness. vomits. reports a headache.
Correct response: vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Flat 30-degree head elevation Trendelenburg's Side-lying
Correct response: 30-degree head elevation Explanation: For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign? Bruising under the eyes Ecchymosis over the mastoid Drainage of cerebrospinal fluid from the ears Drainage of cerebrospinal fluid from the nose
Correct response: Ecchymosis over the mastoid Explanation: With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Subdural hematoma Intracerebral hemorrhage Epidural hematoma Extradural hematoma
Correct response: Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as most responsive. coma. a need for emergency attention. least responsive.
Correct response: coma. Explanation: The Glasgow Coma Scale (GCS) is a tool for assessing a clent's response to stimuli. A 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.
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Autonomic dysreflexia Spinal shock Thrombophlebitis Orthostatic hypotension
Correct response: Autonomic dysreflexia Explanation: Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? Myoclonus Spasticity Akathisia Ataxia
Correct response: Spasticity Explanation: Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.
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 Spasticity of all four extremities Hyperreflexia along with spastic extremities
Correct response: Absence of reflexes along with flaccid extremities Explanation: During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
A 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? Basilar Simple Comminuted Depressed
Correct response: Basilar Explanation: Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
Which of the following is the earliest sign of increasing intracranial pressure (ICP)? Posturing Loss of consciousness Vomiting Headache
Correct response: Loss of consciousness Explanation: The earliest sign of increasing ICP is loss of consciousness. Other manifestations of increasing ICP are vomiting, headache, and posturing.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Monitoring the patency of an indwelling urinary catheter Placing the client in Trendelenburg's position Assessing laboratory test results as ordered Administering zolpidem tartrate (Ambien)
Correct response: Monitoring the patency of an indwelling urinary catheter Explanation: A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
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. Mild TBI. Moderate TBI. Brain death.
Correct response: Severe TBI. Explanation: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
Which is the most common cause of spinal cord injury (SCI)? Motor vehicle crashes Sports-related injuries Falls Acts of violence
Correct response: Motor vehicle crashes Explanation: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.
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 allows for stabilization of the cervical spine along with early ambulation. It is the only device that can be applied for stabilization of a spinal fracture. It is less bulky and traumatizing for the patient to use. The patient can remove it as needed.
Correct response: It allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client has periorbital edema and ecchymosis. The client prefers to rest in the semi-Fowler's position. The client's level of consciousness has improved. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
Correct response: The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. Explanation: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury So that the patient will not have a respiratory arrest
Correct response: Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
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? Examine the skin for any area of pressure or irritation. Raise the head of the bed and place the patient in a sitting position. Empty the bladder immediately. Examine the rectum for a fecal mass.
Correct response: Raise the head of the bed and place the patient in a sitting position. Explanation: The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
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 psychological well-being maintain sufficient integument capillary pressure passive exercise provide a change of scenery
Correct response: maintain sufficient integument capillary pressure Explanation: Changing position every 2 hours relieves pressure over bony prominences and maintains sufficient capillary pressure to promote intact skin integrity.
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 Temporal skull fracture Occipital skull fracture Frontal skull fracture
Correct response: Basilar skull fracture Explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. 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's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
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? Impaired verbal communication Disturbed sensory perception (visual) Risk for injury Dressing or grooming self-care deficit
Correct response: Risk for injury Explanation: Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.
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. Hypertension Bradycardia Tachycardia Hypotension Bradypnea
Correct response: Bradycardia Hypertension Bradypnea Explanation: 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.
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? Tetraplegia Cardiogenic shock Paraplegia Spinal shock
Correct response: Spinal shock Explanation: Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.
A client 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. Administer oxygen as prescribed. Use mechanical ventilation. Maintain a patent airway.
Correct response: Suction the airway. Explanation: Suctioning the airway helps remove secretions. An artificial airway increases the production of respiratory secretions. To prevent hypoxemia, the client may need more oxygen than is available in the room air. An endotracheal tube provides an airway from the nose or mouth to an area above the mainstem bronchi. Mechanical ventilation provides a means to regulate the respiratory rate, volume of air, and percentage of oxygen when a client fails to breathe independently.
Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, tachycardia, nausea, flushed skin severe hypotension, slow heart rate, anxiety, dry skin
Correct response: severe hypertension, slow heart rate, pounding headache, sweating Explanation: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. Coma No brain waves Apnea Absence of brainstem reflexes
Correct response: Absence of brainstem reflexes Apnea Coma Explanation: The three cardinal signs of brain death on clinical examination are coma, the absence of brain stem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brain stem auditory evoked potential, are often used to confirm brain death.
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
Correct response: An area of bruising over the mastoid bone Explanation: Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.
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 Areflexia Paraplegia Tetraplegia
Correct response: Autonomic dysreflexia Explanation: 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. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
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 serous drainage from the nose. The client has an elevated temperature. The client has ecchymosis in the periorbital region.
Correct response: The client has cerebral spinal fluid (CSF) leaking from the ear. Explanation: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased pulse Widened pulse pressure Decreased body temperature Decreased respirations
Correct response: Widened pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations become rapid, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: motor loss in the legs that exceeds that in the arms. nuchal rigidity and Kernig's sign. pupillary changes. raccoon's eyes and Battle sign.
Correct response: raccoon's eyes and Battle sign. Explanation: 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 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.
Correct response: Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Explanation: Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.
The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? Conception is not impaired; the birth process is determined with the physician. Birth via surrogate is best because your baby can be implanted in another woman. Sterilization is best; it would be difficult to care for a baby in your condition. Adoption is an option to complete your family but not put your life in jeopardy.
Correct response: Conception is not impaired; the birth process is determined with the physician. Explanation: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate. Providing information on that suggestion is appropriate.
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.
Correct response: Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Explanation: Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore options B, C, and D are incorrect.
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Out of bed to the chair three times a day Insertion of a nasogastric (NG) tube Serum sodium concentration testing Urine testing for acetone
Correct response: Insertion of a nasogastric (NG) tube Explanation: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.
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 Digital stimulation Bowel surgery A large volume enema
Correct response: Insertion of a nasogastric tube Explanation: Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.
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 Evaluation of nutritional status and metabolic state Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort
Correct response: Lung auscultation and measurement of vital capacity and tidal volume Explanation: In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
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 Administer enemas, as needed Maintain cerebral perfusion pressure from 50 to 70 mm Hg Restrain the client, as indicated
Correct response: Maintain cerebral perfusion pressure from 50 to 70 mm Hg Explanation: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
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? Allowing the client to choose the position of comfort Continuous use of an indwelling catheter Meticulous cleanliness Avoidance of all lotions and lubricants
Correct response: Meticulous cleanliness Explanation: Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.
A 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? Bleeding continues into the intracerebral area. Symptoms will evolve over a period of 1 week. The crash cart with defibrillator is kept nearby. Monitoring is needed as rapid neurologic deterioration may occur.
Correct response: Monitoring is needed as rapid neurologic deterioration may occur. Explanation: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Intracerebral hemorrhage Extradural hematoma Subdural hematoma Epidural hematoma
Correct response: Subdural hematoma Explanation: A subdural hematoma is a collection of blooding between the dura mater and brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
