Neurological Trauma PrepU Ch 61

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 Decorticate Flaccid Normal

Decerebrate

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Autoregulation Herniation Cushing's response Monro-Kellie hypothesis

Herniation

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 will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating."

The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing's reflex? Select all that apply. Apical pulse is 42 beats per minute Systolic blood pressure is 180 mm/Hg Weakness on one side of the body Blood pressure is 140/38 mmHg Urine output over 100 mL/hr

Apical pulse is 42 beats per minute Systolic blood pressure is 180 mm/Hg Blood pressure is 140/38 mmHg

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 Frontal skull fracture Temporal skull fracture Occipital skull fracture

Basilar skull fracture

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? Signs of infection Intake and output Nutritional status Body temperature

Body temperature Explanation: It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage.

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. Bradypnea Hypertension Hypotension Tachycardia Bradycardia

Bradycardia Hypertension Bradypnea 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.

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. Breathing Transferring to a wheelchair Eating Writing Ambulating

Eating Breathing Transferring to a wheelchair Writing

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? Drainage of cerebrospinal fluid from the ears Bruising under the eyes Ecchymosis over the mastoid Drainage of cerebrospinal fluid from the nose

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.

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." What information will the nurse give the husband during discharge teaching? The importance of monitoring urinary elimination Ergonomic principles and body mechanics Nutritional changes for the client with paraplegia Signs and symptoms of chronic back pain that should be reported to the health care provider

Ergonomic principles and body mechanics

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 Eye opening Verbal response Muscle strength Motor response

Eye opening Verbal response Motor response

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed A head elevation of 90 degrees to prevent cerebral swelling Flat

Flat, except for logrolling as needed

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: Absence of brain stem reflexes Apnea Coma Glasgow Coma Scale of 6

Glasgow Coma Scale of 6

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Coma Bradycardia Tachypnea Hemiparesis Hypotension Decreased reactivity of the pupils

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. Tachycardia Hypertension Fever Diaphoresis Nasal congestion

Hypertension Diaphoresis Nasal congestion

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Ineffective cerebral tissue perfusion related to increased intracranial pressure Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury

Ineffective airway clearance related to brain injury

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

Insertion of a nasogastric (NG) tube

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Administers an oral analgesic for pain Shaves the hair around the wound Irrigates the wound to remove debris Administers acetaminophen (Tylenol) for headache

Irrigates the wound to remove debris

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

Monitoring the patency of an indwelling urinary catheter

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

A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? Place in a seated position. Examine the rectum for a fecal mass. Asses the skin for areas of pressure. Palpate the bladder for distention.

Place in a seated position.

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Respiratory pattern Pulse and blood pressure Numbness and tingling Pain level

Pulse and blood pressure

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.

Raise the head of the bed and place the patient in a sitting position.

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: Brain death. Moderate TBI. Mild TBI. Severe TBI.

Severe TBI.

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.

Neurological level of spinal cord injury refers to which of the following? The lowest level at which sensory and motor function is normal The highest level at which sensory and motor function is normal The best possible level of recovery The level of the spinal cord transection

The lowest level at which sensory and motor function is normal

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? Traction with weights and pulleys Cast Turning frame Cervical collar

Traction with weights and pulleys

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased respirations Increased pulse Decreased body temperature Widened pulse pressure

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 decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs.

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

Young age Alcohol use Drug abuse

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 minimally responsive. coma. most responsive. least responsive.

coma The GCS is a tool for assessing a client's response to stimuli. A score of 7 or less is generally interpreted as a coma. The lowest score is 3 (least responsive/deep coma); the highest is 15 (most responsive). A GCS between 3 and 8 is generally accepted as indicating a severe head injury. No category is termed "least" responsive.

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? concussion contusion Diffuse axonal injury Intracranial hemorrhage

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.

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: nitroglycerin (Nitro-Bid). naloxone (Narcan). atracurium (Tracrium). famotidine (Pepcid).

famotidine (Pepcid). Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid).

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? Diffuse axonal injury Intracranial hemorrhage Contusion Concussion

Contusion Explanation: Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

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? Paraplegia Areflexia Tetraplegia Autonomic dysreflexia

Autonomic dysreflexia

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? Sweating Rapid heart rate Runny nose Slight headache

sweating 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.

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 regains bowel elimination capacity client's skin remains clean, dry, and intact client maintains mechanical ventilation with minimal mucus accumulation client reports no discomfort

client maintains mechanical ventilation with minimal mucus accumulation

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: prevent embolism. follow hospital protocol. decrease the potential for brain damage. assess for infection.

decrease the potential for brain damage. Explanation: It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.

At which of the following spinal cord injury levels does the patient have full head and neck control? C3 C4 C2 C5

C5 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.

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 hypertension Spinal shock Rebound hypotension Urinary tract infection

Rebound hypotension

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: to continue IV administration of other scheduled medications. payment status will change if the client isn't sedated. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. nutritional protocol will be effective after the client sedation therapy is tapered.

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. When the client isn't sedated, he may make attempts to remove the ET tube without realizing what he's doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Emphasize complete bed rest Look for a halo sign Have the client avoid physical exertion Look for signs of increased intracranial pressure

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. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. The nurse anticipates that the client has developed __________(chronic subdural hematoma, acute subdural hematoma, stroke) and that ________ (CT Imaging, ECG, coagulation profile )will be ordered.

Chronic subdural hematoma CT imaging of the brain

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? Temporal skull fracture Basilar skull fracture Occipital skull fracture Frontal skull fracture

Basilar skull fracture

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? 48 to 72 hours 6 to 8 hours 12 to 24 hours 18 to 36 hours

18 to 36 hours Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? Grade 2 concussion Grade 4 concussion Grade 3 concussion Grade 1 concussion

Grade 3 concussion Explanation: There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related. A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes

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 Heart rate decrease from 100 to 90 bpm Urinary output increase from 40 to 55 mL/hr Pulse oximetry decrease from 99% to 97% room air

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.

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

severe hypertension, slow heart rate, pounding headache, sweating

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Venous pooling in the extremities Warm skin Bradycardia Tachycardia Profuse bilateral sweating

Venous pooling in the extremities Bradycardia Warm skin

the nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? Administer opioids to the client Provide a dimly lit room Apply an external urinary sheath catheter Turn and reposition the client every 2 hours

Apply an external urinary sheath catheter Explanation: A strategy the nurse can implement to prevent client injury is to use an external sheath catheter for a male client if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the client may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils, and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the client every 2 hours maintains skin integrity.

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? Intubation and mechanical ventilation Immediate craniotomy

Immediate craniotomy Explanation: The client is experiencing an epidural hematoma. 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 (ICP) emergently, remove the clot, and control the bleeding. A craniotomy may be required to remove the clot and control the bleeding. Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the client is awake and conversant. During this lucid interval, the expanding hematoma is compensated for by rapid absorption of cerebrospinal fluid and decreased intravascular volume, both of which help to maintain the ICP within normal limits. When these mechanisms can no longer compensate, even a small increase in the volume of the blood clot produces a marked elevation in ICP. The client then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

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? 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. 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.

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. 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.