NU144- Chapter 68: Management of Patients With Neurologic Trauma

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

Which Glasgow Coma Scale score is indicative of a severe head injury?

7

Which signs are considered cardinal signs of brain death? Select all that apply.

Absence of brainstem reflexes Apnea Coma

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

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

Body temperature

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

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

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

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

Spinal shock

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

Subdural hematoma

concussion

a temporary loss of neurologic function with no apparent structural damage to the brain

contusion

bruising of the brain surface

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

coma

halo vest

external traction device that encircles the head like a halo and stabilizes the cervical spine

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:

famotidine (Pepcid).

primary injury

initial damage to the brain that results from the traumatic event

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Young age Alcohol use Drug abuse

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.

Bradycardia Hypertension Bradypnea

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?

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

incomplete spinal cord lesion

a condition in which there is preservation of the sensory or motor fibers, or both, below the lesion

secondary injury

an insult to the brain subsequent to the original traumatic event

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."

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?

18 to 36 hours

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

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

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?

Flat, except for logrolling as needed

paraplegia

paralysis of the lower extremities with dysfunction of the bowel and bladder from a lesion in the thoracic, lumbar, or sacral region of the spinal cord

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

Contusion

neurogenic bladder

bladder dysfunction that results from a disorder or dysfunction of the nervous system; may result in either urinary retention or bladder overactivity

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?

Autonomic dysreflexia

traumatic brain injury

an injury to the skull or brain that is severe enough to interfere with normal functioning

transection

severing of the spinal cord itself; transection can be complete (all the way through the cord) or incomplete (partially through)

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?

Fever and change in urine clarity

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

Maintain a clear airway to ensure adequate ventilation.

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurologic examination

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse?

Place the patient in a sitting position.

spinal cord injury (SCI)

an injury to the spinal cord, vertebral column, supporting soft tissue, or intervertebral discs caused by trauma

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.

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.

0.5

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

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

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

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

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

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?

Monitoring is needed as rapid neurologic deterioration may occur.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

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

Motor vehicle crashes

traumatic brain injury, open (penetrating)

occurs when an object penetrates the skull, enters the brain, and damages the soft brain tissue in its path (penetrating injury), or when blunt trauma to the head is so severe that it opens the scalp, skull, and dura to expose the brain

traumatic brain injury, closed (blunt)

occurs when the head accelerates and then rapidly decelerates or collides with another object and brain tissue is damaged, but there is no opening through the skull and dura

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure

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

T6

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?

Irrigates the wound to remove debris

tetraplegia

varying degrees of paralysis of both arms and legs, with dysfunction of bowel and bladder from a lesion of the cervical segments of the spinal cord; formerly called quadriplegia

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

Tachycardia

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

complete spinal cord lesion

a condition that involves total loss of sensation and voluntary muscle control below the lesion

autonomic dysreflexia

a life-threatening emergency in patients with spinal cord injury that causes a hypertensive emergency; also called autonomic hyperreflexia

The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

It results from initial damage to the brain from the traumatic event.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg