exam 2

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 client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Concussion Autonomic dysreflexia Spinal shock Contusion

Autonomic dysreflexia

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

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To increase cerebral perfusion pressure To prevent secondary brain injury

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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. Hypotension Tachycardia Bradycardia Bradypnea Hypertension

Bradycardia Bradypnea Hypertension

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Lower back pain Burning sensation on urination Frequency of urination Fever and change in urine clarity

Fever and change in urine clarity

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? Insertion of a nasogastric tube A large volume enema Digital stimulation Bowel surgery

Insertion of a nasogastric tube

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

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

Motor vehicle crashes

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders? The second cervical vertebrae The first thoracic vertebrae The seventh thoracic vertebrae The first lumbar vertebrae

The first thoracic vertebrae

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

Young age Alcohol use Drug abuse

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 emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Occipital skull fracture Temporal skull fracture Frontal skull fracture Basilar skull fracture

Basilar skull fracture

When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? Decerebrate Normal Flaccid Decorticate

Decerebrate

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 Absence of brain stem reflexes Apnea Glasgow Coma Scale of 6

Glasgow Coma Scale of 6

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

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

Subdural hematoma

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 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

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

Subdural

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? Cervical collar Cast Traction with weights and pulleys Turning frame

Traction with weights and pulleys

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.

coma.

Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating severe hypotension, tachycardia, nausea, flushed skin severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, slow heart rate, anxiety, dry skin

severe hypertension, slow heart rate, pounding headache, sweating