prepu management of pts with neurologic trauma.ЁЯШК
The earliest sign of serious impairment of brain circulation related to increased ICP is: a: A change in consciousness. b: A bounding pulse. c: Bradycardia. d: Hypertension.
a change in consciousness
Which of the following types of skull fractures may be evident by Battle's sign? a: Basilar b: Simple c: Comminuted d: Depressed
basilar
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? a: Paraplegia b: Cardiogenic shock c: Spinal shock d: Tetraplegia
spinal shock
Which condition occurs when blood collects between the dura mater and arachnoid membrane? a: Intracerebral hemorrhage b: Epidural hematoma c: Extradural hematoma d: Subdural hematoma
subdural hematoma
The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation? a: Escape of cerebrospinal fluid from the client's ear b: Escape of cerebrospinal fluid from the client's nose c: An area of bruising over the mastoid bone d: A bloodstain surrounded by a yellowish stain on the head dressing
an area of bruising over the mastoid bone
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
decerebrate
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 a: Acts of violence b: Falls c: Sports-related injuries d: Motor vehicle crashes
motor vehicle crashes
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? a: Disturbed sensory perception (visual) b: Risk for injury c: Impaired verbal communication d: Dressing or grooming self-care deficit
risk for injury
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 an elevated temperature. b: The client has serous drainage from the nose. c: The client has cerebral spinal fluid (CSF) leaking from the ear. d: The client has ecchymosis in the periorbital region.
the client has CSF leaking from the ear
