PrepU Chapter 68: Neurologic Trauma

Which is the most common cause of spinal cord injury (SCI)? a. Motor vehicle crashes b. Sports-related injuries c. Falls d. Acts of violence

a. Motor vehicle crashes Rationale: The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.

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

a. severe hypertension, slow heart rate, pounding headache, sweating Rationale: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? a. Myelography b. Neurologic examination c. Radiography d. Computed tomography (CT) scan

b. Neurologic examination Rationale: 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.

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: a. Brain death. b. Severe TBI. c. Mild TBI. d. Moderate TBI.

b. Severe TBI. Rationale: A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.

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

c. Look for signs of increased intracranial pressure Rationale: 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 nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? a. Urine testing for acetone b. Serum sodium concentration testing c. Out of bed to the chair three times a day d. Insertion of a nasogastric (NG) tube

d. Insertion of a nasogastric (NG) tube Rationale: Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

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? a. Rebound hypotension b. Urinary tract infection c. Rebound hypertension d. Spinal shock

a. Rebound hypotension Rationale: 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.

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? a. Thrombophlebitis b. Autonomic dysreflexia c. Spinal shock d. Orthostatic hypotension

b. Autonomic dysreflexia Rationale: Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

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)? a. Restrain the client, as indicated b. Maintain cerebral perfusion pressure from 50 to 70 mm Hg c. Position the client in the supine position d. Administer enemas, as needed

b. Maintain cerebral perfusion pressure from 50 to 70 mm Hg Rationale: The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

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. a. Verbal response b. Intelligence c. Muscle strength d. Eye opening e. Motor response

a. Verbal response d. Eye opening e. Motor response Rationale: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.

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

c. Contusion Rationale: 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.

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? a. Cardiogenic shock b. Tetraplegia c. Spinal shock d. Paraplegia

c. Spinal shock Rationale: Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

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. Urinary output increase from 40 to 55 mL/hr b. Pulse oximetry decrease from 99% to 97% room air c. Temperature increase from 98.0°F to 99.6°F d. Heart rate decrease from 100 to 90 bpm

c. Temperature increase from 98.0°F to 99.6°F Rationale: 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.

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

d. Ineffective airway clearance related to brain injury Rationale: Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

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: a. decrease the potential for brain damage. b. follow hospital protocol. c. assess for infection. d. prevent embolism.

a. decrease the potential for brain damage. Rationale: 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.

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. a. Diaphoresis b. Tachycardia c. Fever d. Nasal congestion e. Hypertension

a. Diaphoresis d. Nasal congestion e. Hypertension Rationale: Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the client may be diaphoretic, a fever does not accompany this condition.

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? a. So that the patient will not have a respiratory arrest b. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord c. To increase cerebral perfusion pressure d. To prevent secondary brain injury

b. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Rationale: 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.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? a. Extreme thirst b. Intake and output c. Nutritional status d. Body temperature

d. Body temperature Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

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? a. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. b. Notify the physician; a headache is an early sign of worsening neurologic status. c. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. d. Reassure the client that a headache is expected and will go away without treatment.

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

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? a. Raise the head of the bed and place the patient in a sitting position. b. Examine the skin for any area of pressure or irritation. c. Empty the bladder immediately. d. Examine the rectum for a fecal mass.

a. Raise the head of the bed and place the patient in a sitting position. Rationale: The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.

A client with a spinal cord injury has full head and neck control when the injury is at which level? a. C1 b. C2 to C3 c. C4 d. C5

d. C5 Rationale: 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.

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. Bradycardia b. Hypertension c. Bradypnea d. Hypotension e. Tachycardia

a. Bradycardia b. Hypertension c. Bradypnea Rationale: 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 finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? a. Increased pulse b. Widened pulse pressure c. Decreased body temperature d. Increased respirations

b. Widened pulse pressure Rationale: 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. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

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? a. contusion b. concussion c. laceration d. skull fracture

b. concussion Rationale: 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.

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? a. Fever and change in urine clarity b. Lower back pain c. Frequency of urination d. Burning sensation on urination

a. Fever and change in urine clarity Rationale: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? a. Watch closely for signs of urinary tract infection. b. Keep accurate intake and output. c. Maintain a diet for the client that is high in protein, vitamins, and calories. d. Avoid range of motion exercises for the client because of spasms.

c. Maintain a diet for the client that is high in protein, vitamins, and calories. Rationale: To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

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 a. coma. b. least responsive. c. most responsive. d. minimally responsive.

a. coma. Rationale: 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.

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

b. Herniation Rationale: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

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? a. Ecchymosis over the mastoid b. Bruising under the eyes c. Drainage of cerebrospinal fluid from the nose d. Drainage of cerebrospinal fluid from the ears

a. Ecchymosis over the mastoid Rationale: 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 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. chronic b. acute c. intracerebral d. subacute

b. acute Rationale: 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.

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply. a. Weakness on one side of the body b. Sleeps for short periods of time c. Slurred speech d. Vomiting e. Headache

a. Weakness on one side of the body c. Slurred speech d. Vomiting Rationale: Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately.

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 extradural hematoma c. A subdural hematoma d. An epidural hematoma

a. An intracerebral hematoma Rationale: 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.

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? a. Irrigates the wound to remove debris b. Administers acetaminophen (Tylenol) for headache c. Administers an oral analgesic for pain d. Shaves the hair around the wound

a. Irrigates the wound to remove debris Rationale: Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

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? a. Ergonomic principles and body mechanics b. Signs and symptoms of chronic back pain that should be reported to the health care provider c. The importance of monitoring urinary elimination d. Nutritional changes for the client with paraplegia

a. Ergonomic principles and body mechanics Rationale: The husband's statement indicates a need for teaching in regard to client mobility and transfer techniques. Although urinary elimination, nutrition, and pain are components of care for clients with paraplegia, education about ergonomic principles and body mechanics is most appropriate at this time based on the husband's statement.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? a. Insertion of a nasogastric tube b. Digital stimulation c. Bowel surgery d. A large volume enema

a. Insertion of a nasogastric tube Rationale: Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

Which condition occurs when blood collects between the dura mater and arachnoid membrane? a. Subdural hematoma b. Extradural hematoma c. Epidural hematoma d. Intracerebral hemorrhage

a. Subdural hematoma Rationale: A subdural hematoma is a collection of blood between the dura mater and the 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.

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: a. famotidine (Pepcid). b. nitroglycerin (Nitro-Bid). c. atracurium (Tracrium). d. naloxone (Narcan).

a. famotidine (Pepcid). Rationale: 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). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

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. Symptoms will evolve over a period of 1 week. b. Monitoring is needed as rapid neurologic deterioration may occur. c. Bleeding continues into the intracerebral area. d. The crash cart with defibrillator is kept nearby.

b. Monitoring is needed as rapid neurologic deterioration may occur. Rationale: 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.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? a. Ataxia b. Spasticity c. Akathisia d. Myoclonus

b. Spasticity Rationale: 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.

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? a. The client has ecchymosis in the periorbital region. b. The client has cerebral spinal fluid (CSF) leaking from the ear. c. The client has an elevated temperature. d. The client has serous drainage from the nose.

b. The client has cerebral spinal fluid (CSF) leaking from the ear. Rationale: 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.

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: a. nutritional protocol will be effective after the client sedation therapy is tapered. b. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. c. to continue IV administration of other scheduled medications. d. payment status will change if the client isn't sedated.

b. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. Rationale: 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. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

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

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

The earliest sign of serious impairment of brain circulation related to increased ICP is: a. Hypertension. b. A bounding pulse. c. A change in consciousness. d. Bradycardia.

c. A change in consciousness. Rationale: The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? a. Spasticity of all four extremities b. Positive Babinski's reflex along with spastic extremities c. Absence of reflexes along with flaccid extremities d. Hyperreflexia along with spastic extremities

c. Absence of reflexes along with flaccid extremities Rationale: 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.

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? a. Grade 4 concussion b. Grade 2 concussion c. Grade 3 concussion d. Grade 1 concussion

c. Grade 3 concussion Rationale: There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). 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 (Ruff et al., 2009).

The most important nursing priority of treatment for a patient with an altered LOC is to: a. Position the patient to prevent injury and ensure dignity. b. Prevent dehydration and renal failure by inserting an IV line for fluids and medications. c. Maintain a clear airway to ensure adequate ventilation. d. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain.

c. Maintain a clear airway to ensure adequate ventilation. Rationale: The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? a. Cerebral b. Intracerebral c. Subdural d. Epidural

c. Subdural Rationale: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.

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? a. Application of Halo traction b. Insertion of Crutchfield tongs c. Hypophysectomy d. Burr holes

d. Burr holes Rationale: 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.

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. Decorticate b. Flaccid c. Normal d. Decerebrate

d. Decerebrate Rationale: 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. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? a. Avoid sedation. b. Keep the head of the client's bed flat. c. Cluster all procedures together. d. Keep the client's neck in a neutral position (no flexing).

d. Keep the client's neck in a neutral position (no flexing). Rationale: To assist in controlling ICP in clients with severe brain injury, the following are recommended: elevate the head of the bed as prescribed (gravity helps drain fluid), maintain head/neck in neutral alignment (no twisting or flexing), give sedation as ordered to prevent agitation, and avoid noxious stimuli (scatter procedures so that client does not become overtired).

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? a. Turning frame b. Cast c. Cervical collar d. Traction with weights and pulleys

d. Traction with weights and pulleys Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply. a. Older adult b. Young age c. Low-income community d. Substance abuse e. Male gender

b. Young age d. Substance abuse e. Male gender Rationale: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.

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: a. Absence of brain stem reflexes b. Apnea c. Glasgow Coma Scale of 6 d. Coma

c. Glasgow Coma Scale of 6 Rationale: The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.

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

c. Young age d. Alcohol use e. Drug abuse Rationale: The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.