Med Surg Chapter 39 (Test 2)

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight.

The nurse is caring for a client who is scheduled for a cervical diskectomy the following day. During health education, the client should be made aware of what potential complications?

Hematoma at the surgical site

A patient has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication can the nurse provide as ordered by the physician to decrease the blood pressure?

Hydralazine hydrochloride (Apresoline) IV administered slowly

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:

Increased intracranial pressure (ICP)

A field hockey coach was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic testing, it was determined that the client suffered a skull fracture with moderate symptoms. What would the nurse anticipate the nursing care plan to include? Select all that apply.

Monitor for a halo sign. Prepare for the possibility of a seizure.

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension

Monitor the client's BP before and during position changes.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

Motor vehicle accidents

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

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 receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for:

chronic traumatic encephalopathy.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?

client maintains mechanical ventilation with minimal mucus accumulation

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?

"The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel."

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

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

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.

Alcohol or drug use Young age

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?

An area of bruising over the mastoid bone

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

A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring?

Applying thigh-high elastic stockings

The nurse responds to the call light of a client who has had a cervical diskectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action?

Call the surgeon to report the client's pain.

A halo sign is indicative of which of the following complication of brain injury?

Cerebrospinal fluid (CFS) leak

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping?

Assist the family in setting appropriate short-term goals.

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk?

Change the client's position frequently.

A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

Ineffective breathing pattern

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

A nurse is caring for a patient who is exhibiting signs and symptoms of autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

Bradycardia and hypertension

The ED nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

Bruising over the mastoid

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

A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention?

Emergency craniotomy

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action?

Initiating (ROM) exercises as soon as possible after the injury

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.

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status?

Level of consciousness

A client is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this client to evaluate the brain structure?

MRI

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

Maintain a clear airway to ensure adequate ventilation.

An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?

Maintain the patency of the patient's airway.

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence.

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 client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

Spinal shock

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

Spinal shock

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

T6

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 client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?

Urinary catheters often lead to urinary tract infections.

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

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

Watchful waiting and close monitoring

Which of the following is a sign of increasing ICP?

Widening pulse pressure

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

A client who was involved in a motor vehicle collision is brought to the emergency department. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders that the client be prepared for surgery. In preparing the client for surgery, which would be the least likely nursing intervention?

preoperative sedation

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.