Module 1 : Spinal Cord Injuries - ML6
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." "I will change the vest liner periodically." "I'll check under the liner for blisters and redness." "If a pin becomes detached, I'll notify the surgeon."
"I can apply powder under the liner to help with sweating." Explanation: Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care. Chapter 63: Management of Patients with Neurologic Trauma - Page 2075-2078
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. _____________________mL
0.5 Explanation: (50 mg/80 mg) X 0.8 mL = 0.5 mL.
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. ___________________________mL.
1.6 Explanation: (100 mg/125 mg) x 2 mL = 1.6 mL. Chapter 63: Management of Patients with Neurologic Trauma - Page 2074-2075
The earliest sign of serious impairment of brain circulation related to increased ICP is: A bounding pulse. A change in consciousness. Hypertension. Bradycardia.
A change in consciousness. Explanation: The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately. Chapter 63: Management of Patients with Neurologic Trauma - Page 2058
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? Escape of cerebrospinal fluid from the client's ear Escape of cerebrospinal fluid from the client's nose An area of bruising over the mastoid bone A bloodstain surrounded by a yellowish stain on the head dressing
An area of bruising over the mastoid bone Explanation: 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 sign). Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak. Chapter 63: Management of Patients with Neurologic Trauma - Page 2056-2057
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 extradural hematoma A subdural hematoma An intracerebral hematoma An epidural hematoma
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2059-2060
A client with a spinal cord injury at T8 would likely retain normal motor and somatosensory function of her: Bowels Arms Bladder Perineal musculature
Arms Explanation: A spinal cord injury at T8 would likely allow the client to retain normal function of the upper extremities, while innervations governing the function of the bowels, bladder, and perineum would be severed. Chapter 15: Disorders of Motor Function - Page 404
A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF? Assess for a halo sign Assess for bloody drainage Assess for a wing sign Assess for crepitus around the nose
Assess for a halo sign Explanation: Most clients are hospitalized for at least 24 hours after a significant head injury. The nurse examines the client to identify signs of head trauma and tests drainage from the nose or ear. To detect any CSF drainage, the nurse looks for a halo sign, which is a blood stain surrounded by a clear or yellowish stain. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
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? Areflexia Autonomic dysreflexia Paraplegia Tetraplegia
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
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? Autonomic dysreflexia Spinal shock Contusion Concussion
Autonomic dysreflexia Explanation: Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? To prevent secondary brain injury To increase cerebral perfusion pressure So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2068
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? Application of Halo traction Insertion of Crutchfield tongs Burr holes Hypophysectomy
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2059
A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5
C5 Explanation: At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control. Chapter 63: Management of Patients with Neurologic Trauma - Page 2070-2074
A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? Fluid and electrolyte maintenance Intubation and mechanical ventilation Seizure prophylaxis and prevention Cervical and spinal immobilization
Cervical and spinal immobilization Explanation: Any client with a head injury is presumed to have a cervical spine injury until proven otherwise. The client is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI (spinal cord injury) documented. This client's x-rays were pending so spinal precautions should be maintained and are the priority. Primary injury to the brain is defined as the consequence of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries. The greatest opportunity for decreasing TBI (traumatic brain injury) is the implementation of prevention strategies. Treatment for clients with suspected increased intracranial pressure (ICP) also includes ventilator support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and management of pain and anxiety. Clients who are comatose are intubated and mechanically ventilated to ensure adequate oxygenation and to protect their airway. No information was provided on current ICP. The client was not fully orientated so he/she was transferred to the ICU for closer monitoring. Chapter 63: Management of Patients with Neurologic Trauma - Page 2060
The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful? Adoption is an option to complete your family but not put your life in jeopardy. Conception is not impaired; the birth process is determined with the physician. Sterilization is best; it would be difficult to care for a baby in your condition. Birth via surrogate is best because your baby can be implanted in another woman.
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, or sterilization is not appropriate. Providing information is appropriate. Chapter 63: Management of Patients with Neurologic Trauma - Page 2080
The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful? Sterilization is best; it would be difficult to care for a baby in your condition. Conception is not impaired; the birth process is determined with the physician. Adoption is an option to complete your family but not put your life in jeopardy. Birth via surrogate is best because your baby can be implanted in another woman.
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, or sterilization is not appropriate. Providing information is appropriate. Chapter 63: Management of Patients with Neurologic Trauma - Page 2080
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide? Give the client some orange juice and sugar. Disimpact the stool from the anal vault. Elevate the head of the bed. Insert an indwelling catheter.
Elevate the head of the bed. Explanation: Autonomic dysreflexia is a clinical emergency, and without prompt and adequate treatment, convulsions, loss of consciousness, and even death can occur. The major components of treatment include monitoring blood pressure while removing or correcting the initiating cause or stimulus. The person should be placed in an upright position, and all support hose or binders should be removed to promote venous pooling of blood and reduce venous return. Chapter 15: Disorders of Motor Function - Page 911
A client who sustained a complete C6 spinal cord injury 6 months ago has been admitted to the hospital for pneumonia. The nurse observes the client with diaphoresis above the level of C6 and the blood pressure is 260/140 mm Hg. What is the first intervention the nurse should provide? Insert an indwelling catheter. Disimpact the stool from the anal vault. Give the client some orange juice and sugar. Elevate the head of the bed.
Elevate the head of the bed. Explanation: Autonomic dysreflexia is a clinical emergency, and without prompt and adequate treatment, convulsions, loss of consciousness, and even death can occur. The major components of treatment include monitoring blood pressure while removing or correcting the initiating cause or stimulus. The person should be placed in an upright position, and all support hose or binders should be removed to promote venous pooling of blood and reduce venous return. Chapter 15: Disorders of Motor Function - Page 911
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? Subdural hematoma Epidural hematoma Extradural hematoma Intracranial hematoma
Epidural hematoma Explanation: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration. Chapter 63: Management of Patients with Neurologic Trauma - Page 2058-2059
The nurse caring for a client diagnosed with a spinal cord injury notes early signs and symptoms of atrophy. Which of the following is the most appropriate nursing action? Collaborate with the physical therapist and immobilize the client's extremities temporarily. Educate the client about the importance of frequent position changes. Increase the frequency of passive range-of-motion (ROM) exercises. Limit the amount of assistance provided with ADLs.
Increase the frequency of passive range-of-motion (ROM) exercises. Explanation: To prevent atrophy, ROM exercises must be done at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome. Chapter 63: Management of Patients with Neurologic Trauma - Page 2082
The nurse caring for a client diagnosed with a spinal cord injury notes early signs and symptoms of atrophy. Which of the following is the most appropriate nursing action? Increase the frequency of passive range-of-motion (ROM) exercises. Educate the client about the importance of frequent position changes. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Limit the amount of assistance provided with ADLs.
Increase the frequency of passive range-of-motion (ROM) exercises. Explanation: To prevent atrophy, ROM exercises must be done at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome. Chapter 63: Management of Patients with Neurologic Trauma - Page 2082
The nurse caring for a client diagnosed with a spinal cord injury notes early signs and symptoms of atrophy. Which of the following is the most appropriate nursing action? Increase the frequency of passive range-of-motion (ROM) exercises. Collaborate with the physical therapist and immobilize the client's extremities temporarily. Educate the client about the importance of frequent position changes. Limit the amount of assistance provided with ADLs.
Increase the frequency of passive range-of-motion (ROM) exercises. Explanation: To prevent atrophy, ROM exercises must be done at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome. Chapter 63: Management of Patients with Neurologic Trauma - Page 2082
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? The patient can remove it as needed. 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.
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2075
A client with an acute spinal cord injury is developing spinal shock. The nurse should perform which priority assessment? Paresthesia of the extremities below the injury Inability to move lower extremities Loss of tendon reflexes below the injury Vasoconstriction causing hypertension
Loss of tendon reflexes below the injury Explanation: Spinal shock is characterized by flaccid paralysis, not paresthesia, with loss of tendon reflexes below the level of injury, absence of somatic and visceral sensations below the level of injury, and loss of bowel and bladder function. Loss of systemic sympathetic vasomotor tone may result in vasodilation, increased venous capacity, and hypotension. The spinal cord injury, not spinal shock, is the cause of the inability to move lower extremities. Chapter 15: Disorders of Motor Function - Page 403
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 Meticulous cleanliness Continuous use of an indwelling catheter Avoidance of all lotions and lubricants
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
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? The crash cart with defibrillator is kept nearby. Monitoring is needed as rapid neurologic deterioration may occur. Bleeding continues into the intracerebral area. Symptoms will evolve over a period of 1 week.
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. Reference: Chapter 63: Management of Patients with Neurologic Trauma - Page 2058-2059
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Monitoring the patency of an indwelling urinary catheter Administering zolpidem tartrate (Ambien) Placing the client in Trendelenburg's position Assessing laboratory test results as ordered
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
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 Falls Sports-related injuries Motor vehicle crashes Acts of violence
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2070
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Computed tomography (CT) scan Neurologic examination Radiography Myelography
Neurologic examination Explanation: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma. Chapter 63: Management of Patients with Neurologic Trauma - Page 2060
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 Sciatic nerve pain Paralysis Herniation
Paresthesia Explanation: When a client reports numbness and tingling in an area, the client 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. Chapter 63: Management of Patients with Neurologic Trauma - Page 1134
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? 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. Reassure them that progress will be made, but it takes time.
Provide factual information and emotional support. Explanation: During the most acute phase of injury, family members 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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2066
A client has sustained an acute spinal cord injury in a fall from a tree stand during a hunting trip. The client will require surgical intervention for the unstable spinal cord. What does the nurse recognize is the goal of early surgical intervention for this client? Prevent cord edema. Ensure the client will have full use of the legs and arms. Provide internal skeletal stabilization. Fuse the spine to limit movement.
Provide internal skeletal stabilization. Explanation: The goal of early surgical intervention for an unstable spine is to provide internal skeletal stabilization so that early mobilization and rehabilitation can occur. Chapter 15: Disorders of Motor Function - Page 404
A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? Rebound hypotension Spinal shock Urinary tract infection Rebound hypertension
Rebound hypotension Explanation: When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
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? Dressing or grooming self-care deficit Impaired verbal communication Risk for injury Disturbed sensory perception (visual)
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2060
Which condition occurs when blood collects between the dura mater and arachnoid membrane? Subdural hematoma Intracerebral hemorrhage Extradural hematoma Epidural hematoma
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the 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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2056
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? Let the airway stay as it currently is. Administer oxygen as prescribed. Suction the airway. Use mechanical ventilation.
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2077
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? S2 T10 L4 T6
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T10 T6 L4 S2
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has serous drainage from the nose. The client has an elevated temperature. The client has ecchymosis in the periorbital region. The client has cerebral spinal fluid (CSF) leaking from the ear.
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2057
Neurological level of spinal cord injury refers to which of the following? The highest level at which sensory and motor function is normal The level of the spinal cord transection The best possible level of recovery The lowest level at which sensory and motor function is normal
The lowest level at which sensory and motor function is normal Explanation: "Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal. Chapter 63: Management of Patients with Neurologic Trauma - Page 2070-2072
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Electric or modified manual wheelchair, needs transfer assistance Cane Voice or sip-n-puff controlled electric wheelchair The patient will be able to ambulate independently.
The patient will be able to ambulate independently. Explanation: Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device. Chapter 63: Management of Patients with Neurologic Trauma - Page 2074
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Electric or modified manual wheelchair, needs transfer assistance The patient will be able to ambulate independently. Cane Voice or sip-n-puff controlled electric wheelchair
The patient will be able to ambulate independently. Explanation: Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device. Chapter 63: Management of Patients with Neurologic Trauma - Page 2074
A client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of their urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Overuse of urinary catheters can exacerbate nerve damage. Urinary catheters should not remain in place for more than 7 days. Urinary retention can have serious consequences in clients with SCIs. Urinary function is permanently lost following an SCI.
Urinary retention can have serious consequences in clients with SCIs. Explanation: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs. Chapter 63: Management of Patients with Neurologic Trauma - Page 2078
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 intracerebral subacute
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2059
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 chronic subacute intracerebral
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2059
While snowboarding, a client 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? skull fracture concussion laceration contusion
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2060
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: loss of the sensation of pain and temperature on the side opposite the injury. loss of motor power, pain, and temperature sensation below the level of the lesion. loss of motor power and sensation in the upper extremities. preservation of a sense of touch below the level of the lesion.
loss of motor power and sensation in the upper extremities. Explanation: Characteristics of a central cord injury include motor deficits (in the upper extremities compared to the lower extremities; sensory loss varies but is more pronounced in the upper extremities); bowel/bladder dysfunction is variable, or function may be completely preserved. Chapter 63: Management of Patients with Neurologic Trauma - Page 2071
A recently injured (3 months ago) client with a spinal cord injury at T4 to T5 is experiencing a complication. He looks extremely ill. The nurse recognizes this as autonomic dysreflexia (autonomic hyperreflexia). His BP is 210/108; skin very pale; gooseflesh noted on arms. The priority nursing intervention would be to: scan his bladder to make sure it is empty. check the mouth/throat for pustules and redness. assess calves of legs for redness, warmth, or edema. check the jugular vein for distention.
scan his bladder to make sure it is empty. Explanation: Autonomic hyperreflexia, an acute episode of exaggerated sympathetic reflex responses that occur in persons with injuries at T6 and above, in which central nervous system (CNS) control of spinal reflexes is lost, does not occur until spinal shock has resolved and autonomic reflexes return. Autonomic dysreflexia is characterized by vasospasm, hypertension ranging from mild to severe, skin pallor, and gooseflesh associated with the piloerector response. In many cases, the dysreflexic response results from a full bladder. There is no indication the client has right-sided heart failure (jugular vein distention); has a DVT (calf redness, warmth, or edema); or has strep throat (pustules and red throat/tonsils). Chapter 15: Disorders of Motor Function - Page 407
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 reports a headache. reports generalized weakness. sleeps for short periods of time. vomits.
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. Chapter 63: Management of Patients with Neurologic Trauma - Page 2058-2060
