Med Surg: Chapter 45: Nursing Management: Patients With Neurologic Trauma: PREPU
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? A Monro-Kellie B Dawn phenomenon C Hashimoto's disease D Cushing's
A
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? A An intracerebral hematoma B An epidural hematoma C A subdural hematoma D An extradural hematoma
A
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? A Decerebrate B Flaccid C Normal D Decorticate
A 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.
A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture? A Basilar B Comminuted C Linear D Simple
A n area of ecchymosis (bruising) may be seen over the mastoid (Battle sign) in a basilar skull fracture. Basilar skull fractures are also suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). A simple (linear) fracture is a break in bone continuity. A comminuted fracture refers to a splintered or multiple fracture line.
A client with quadriplegia is in spinal shock. What finding should the nurse expect? A Absence of reflexes along with flaccid extremities B Positive Babinski's reflex along with spastic extremities C Hyperreflexia along with spastic extremities D Spasticity of all four extremities
A 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 client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging? A Mannitol B Half-normal saline (0.45% NSS) C Dextrose 5% in water (D5W) D One-third normal saline (0.33% NSS)
A With increasing ICP, hypertonic solutions, like mannitol, are used to decrease swelling in the brain cells. D5W, 0.45% NSS, and 0.33% NSS are all hypotonic solutions that will move more fluid into the cells, worsening the ICP.
A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? A A slight reddening of the skin surrounding the insertion site B A small amount of yellow drainage at the left pin insertion site C Pain at the insertion site D Crust around the pin insertion site
B
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? A intracerebral B subacute C acute D chronic
C
A patient with a head injury is being assessed for altered LOC and increased intracranial pressure (ICP). The patient's last ICP reading was 16 mm Hg. The nurse understands that treatment for increased ICP will be initiated at a pressure greater than: A 19 mm Hg. B 20 mm Hg. C 21 mm Hg. D 18 mm Hg.
C ICP is usually measured in the lateral ventricles, with normal pressure being 10 to 21 mm Hg. Treatment of increased ICP is generally initiated at a pressure greater than 21 mm Hg.
Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what? A Teach the patient to perform the Valsalva maneuver B Keep the head of bed (HOB) flat at all times C Administer antipyretics on a p.r.n. basis D Perform endotracheal suctioning every hour
C It is important to manage temperature elevations in a patient with suspected increased ICP. A hyperthermic state causes increased ICP. The HOB should be elevated 30 degrees. Suctioning should be done on a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided because this causes increased ICP.
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 A sleeps for short periods of time. B reports generalized weakness. C vomits. D reports a headache
C 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.
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? A The crash cart with defibrillator is kept nearby. B Bleeding continues into the intracerebral area. C Symptoms will evolve over a period of 1 week. D Monitoring is needed as rapid neurologic deterioration may occur.
D
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? A constricted response B rapid response C equal response D unequal response
D In increased ICP, the pupil response is unequal. One pupil responds more sluggishly than the other or becomes fixed and dilated
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A Myoclonus B Akathisia C Ataxia D Spasticity
D 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.
Ataxia means what?
impaired coordination; Impaired balance or coordination, can be due to damage to brain, nerves, or muscles.
Akathisia means what?
inability to sit still; Restlessness
Myoclonus means what?
the sudden, involuntary jerking of a muscle or group of muscles
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? A Temperature increase from 98.0°F to 99.6°F B Heart rate decrease from 100 to 90 bpm C Urinary output increase from 40 to 55 mL/hr D Pulse oximetry decrease from 99% to 97% room air
A 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.
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? A Out of bed to the chair three times a day B Insertion of a nasogastric (NG) tube C Serum sodium concentration testing D Urine testing for acetone
B
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? A Drainage of cerebrospinal fluid from the ears B Bruising under the eyes C Ecchymosis over the mastoid D Drainage of cerebrospinal fluid from the nose
C 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
The initial sign of increasing intracranial pressure (ICP) includes A headache. B vomiting. C herniation. D decreased level of consciousness.
D
Which condition occurs when blood collects between the dura mater and arachnoid membrane? A Extradural hematoma B Intracerebral hemorrhage C Epidural hematoma D Subdural hematoma
D 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.
Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation? A Glycerine B Hypertonic saline C Glucose D Mannitol
D Mannitol is considered the "gold standard" for reducing increased ICP.
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? A Have the client avoid physical exertion B Look for signs of increased intracranial pressure C Emphasize complete bed rest D Look for a halo sign
B 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
A cliient is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because A shivering in hypothermia can increase ICP. B hypothermia is indicative of malaria. C hypothermia can cause death. D hypothermia is indicative of severe meningitis.
A The nurse should avoid hypothermia in a client with increased ICP because hypothermia causes shivering. Shivering, in turn, can increase intracranial pressure. Hypothermia in a client with ICP does not indicate malaria or meningitis and is not likely to cause death.
A patient admitted for the treatment of a nondepressed skull fracture has been leaking clear fluid from his nose, and glucose testing confirms that it is cerebrospinal fluid (CSF). This development necessitates what nursing action? A Performing gentle nasal suctioning at 20 to 30 mm Hg B Positioning the patient side-lying C Elevating the head of the bed to 30 degrees D Insertion of a nasogastric (NG) tube to low suction
C In patients with CSF leakage, the head is elevated 30 degrees to reduce intracranial pressure and promote spontaneous closure of the leak. Suctioning and the insertion of an NG tube are contraindicated due to the risk of trauma.
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. A Hypotension B Bradycardia C Bradypnea D Hypertension E Tachycardia
B, C, D
The victim of a motor vehicle accident has been admitted with massive trauma, including traumatic brain injury. Emergency treatment of increased intracranial pressure (ICP) has failed to resolve the problem, and monitoring reveals the ominous presence of Cushing's triad. What assessment findings would be consistent with this clinical phenomenon? A pH 7.2; PaO2 72 mm Hg; HCO3 20 mEq/L B HR 38 beats per minute; BP 198/107 mm Hg; RR 7 breaths per minute C PaO2 70 mm Hg; RR 12 breaths per minute; HR 116 beats per minute D Temperature 104°F (40°C); RR 33 breaths per minute; HR 111 beats per minute
B When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad