Test 3 Neurological Disorders #5 - From Mom
When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). B. Emergent; the client is poorly oxygenated. C. Normal D. Significant; the client has alveolar hypoventilation.
Correct Answer: A. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. A subdural hematoma forms because of an accumulation of blood under the dura mater, one of the protective layers to the brain tissue under the calvarium. Option B: Oxygenation is evaluated through PaO2 and oxygen saturation. The clinician must begin immediate medical management. These measures include sedation, neuromuscular blockade when appropriate, moderate hyperventilation to a Pc02 (32 to 36), adequate oxygenation to maintain Sp02 greater than 95%, head elevation, and avoidance of hyperthermia. Option C: Often, the bleeding is undetected initially, discovered as a chronic subdural hematoma. When there is a sufficient accumulation of blood to occupy a large intracranial space, the brain midline shifts toward the opposite side, encroaching on the brain structures against the inner surface of the calvarium after decreasing the volume of the lateral third and fourth ventricles. As the intracranial space becomes limited, the volumetric forces push the uncal portion of the temporal lobe toward the foramen magnum causing herniation of the brain. Option D: Alveolar hypoventilation would be reflected in an increased PaCO2. The infusion of hypertonic saline or mannitol serves to decrease intracranial pressure by promoting osmotic changes in the brain and transiently affecting the rheological properties of the cerebral blood flow, respectively.
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? A. Evaluate urine specific gravity. B. Anticipate treatment for renal failure. C. Provide emollients to the skin to prevent breakdown. D. Slow down the IV fluids and notify the physician.
Correct Answer: A. Evaluate urine specific gravity. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce the antidiuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Option B: There's no evidence that the client is experiencing renal failure. The most common findings in patients with diabetes insipidus are polydipsia, polyuria, and nocturia. Additional symptoms in patients with diabetes insipidus may include weakness, lethargy, fatigue, and myalgias. Option C: Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Central diabetes insipidus is diagnosed when there is evidence of plasma hyperosmolality (greater than 300 mosm/l), urine hyperosmolarity (less than 300 mosm/l or urine/plasma osmolality less than 1), with polyuria (urinary volume greater than 4 mL/kg/hr to 5 mL/kg/hr for two consecutive hours after surgery). Option D: Slowing the rate of IV fluid would contribute to dehydration when polyuria is present. In cases of nephrogenic diabetes insipidus, water deprivation suboptimally increases urine osmolality. DDAVP minimally increases urine osmolality in partial nephrogenic diabetes insipidus, with no increase in urine osmolality in complete nephrogenic diabetes insipidus.
A client who is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? A. Laceration of the middle meningeal artery. B. Rupture of the carotid artery. C. Thromboembolism from a carotid artery. D. Venous bleeding from the arachnoid space.
Correct Answer: A. Laceration of the middle meningeal artery. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. Most epidural hematomas result from arterial bleeding from a branch of the middle meningeal artery. The anterior meningeal artery or dural arteriovenous (AV) fistula at the vertex may be involved. Option B: Embolic strokes occur when clots migrate from the source to block more distal cerebral arteries causing cessation of brain tissue perfusion and ischemia. The embolic source can be cardiac, aortic, arterial, from a venous origin in the pelvis or lower limbs with the presence of a cardiac shunt resulting in paradoxical embolism, or an unknown source. Option C: An embolic stroke is a thromboembolism from a carotid artery that ruptures. Emboli can happen due to different mechanisms including blood stasis in an abnormal, structurally enlarged left cardiac chamber such as left ventricular aneurysm with subsequent thrombus formation, material detachment from structurally abnormal calcific degenerative valves, or embolus passage from the venous to the arterial circulation (paradoxical embolism) because of the presence of right to left cardiac shunt such as Patent Foramen Ovale (PFO). Option D: Venous bleeding from the arachnoid space is usually observed with a subdural hematoma. Up to 10% of EDHs are due to venous bleeding following the laceration of a dural venous sinus. In adults, up to 75% of EDHs occur in the temporal region. However, in children, they occur with similar frequency in the temporal, occipital, frontal, and posterior fossa regions.
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? A. Reposition the client to avoid neck flexion. B. Administer 1 g Mannitol IV as ordered. C. Increase the ventilator's respiratory rate to 20 breaths/minute. D. Administer 100 mg of pentobarbital IV as ordered.
Correct Answer: A. Reposition the client to avoid neck flexion. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. Elevate the head of the bed to greater than 30 degrees. Keep the neck midline to facilitate venous drainage from the head. Nursing care must pay close attention to changes in neurologic status, any change in vitals such as an increasingly erratic heart rate, development of bradycardia, accurate and equal intake and output when having diuresis, and maintenance of proper blood pressure. Option B: Osmotic agents can be used to create an osmotic gradient across blood thereby drawing fluid intravascularly and decreasing cerebral edema. Mannitol was the primary agent used at doses of 0.25 to 1 g/kg body weight and is thought to exert its greatest benefit by decreasing blood viscosity and to a lesser extent by decreasing blood volume. Side effects of mannitol use are eventual osmotic diuresis and dehydration as well as renal injury if serum osmolality exceeds 320 mOsm. Option C: Hypercarbia lowers serum pH and can increase cerebral blood flow contributing to rising ICP, hence hyperventilation to lower pCO2 to around 30 mm Hg can be transiently used. Option D: If nursing measures prove ineffective notify the physician, who may prescribe pentobarbital. Pentobarbital is a drug within the barbiturate class that works primarily on the central nervous system. Common off-label uses are for control of intracranial pressure in patients with severe brain injuries, cerebral ischemia, and those receiving treatment for Reye syndrome.
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? A. Position the client flat in bed. B. Check the fluid for dextrose with a dipstick. C. Suction the nose to maintain airway patency. D. Insert nasal and ear packing with sterile gauze.
Correct Answer: B. Check the fluid for dextrose with a dipstick. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. CSF Leak is a condition in which CSF is able to escape from the subarachnoid space through a hole in the surrounding dura. The volume of CSF lost in a leak is very variable, ranging from insignificant to very substantial amounts. Option A: Placing the client flat in bed may increase ICP and promote pulmonary aspiration. If the loss of CSF is great enough, spontaneous intracranial hypotension (SIH) may occur. SIH most often presents with a positional headache caused by downward displacement of the brain due to loss of buoyancy previously provided by the CSF. Posterior neck stiffness, nausea, and vomiting are also common symptoms. Option C: The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Diagnosis is aided by typical MRI findings, such as an increase of intracranial venous volume, pituitary hyperemia, enhanced pachymeninges, and descent of the brain. Many cases of SIH resolve without any treatment. Option D: Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection. Conservative approaches such as bed rest, hydration, and increased caffeine intake may also prove to be effective; however, more drastic measures may be necessary.
A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? A. Bloody drainage from the ears B. Frequent swallowing C. Guaiac-positive stools D. Hematuria
Correct Answer: B. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. In the occurrence of a leak in the postoperative period, the patient is advised bed rest, and a lumbar drain is placed. If the leak does not improve in 24 hours, exploration and closure of the defect are to be done. Worsening of vision as a result of bleeding or manipulation and arterial hemorrhage are other immediate complications. Option A: Blood or fluid draining from the ear may indicate a basilar skull fracture. Basilar skull fractures most commonly involve the temporal bones but may involve the occipital, sphenoid, ethmoid, and the orbital plate of the frontal bone as well. Several clinical exam findings highly predictive of basilar skull fractures include hemotympanum, cerebrospinal fluid (CSF) otorrhea or rhinorrhea, Battle sign (retroauricular or mastoid ecchymosis), and raccoon eyes (periorbital ecchymosis). Option C: If the patient's fecal occult blood test does not turn blue, it is negative. If the card turns blue, this is positive and requires further gastroenterological workup. Occult fecal blood can be present secondary to several etiologies. Neoplastic causes include adenocarcinoma, gastrointestinal metastasis, lymphoma, and leiomyosarcoma. Inflammatory causes include Crohn disease, ulcerative colitis, gastritis, peptic ulcer disease, and diverticular bleeding. Option D: Hematuria is the presence of blood in the urine. Hematuria can be gross or microscopic. Gross hematuria is visible blood in the urine. Microscopic hematuria refers to the detection of blood on urinalysis or urine microscopy. Hematuria is usually caused by a genitourinary disease although systemic diseases can also manifest with blood in the urine. Hematuria is divided into glomerular and nonglomerular hematuria to help in evaluation and management.
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? A. Decreased urine output or oliguria B. Hypertension and bradycardia C. Respiratory depression D. Symptoms of shock
Correct Answer: B. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect. C5 to C7 are responsible for deep tendon reflexes of the biceps, brachioradialis, and triceps respectively. C5 controls shoulder abduction with the aid of C4 and elbow flexion with the aid of C6. C6 to C7 are responsible for elbow extension, wrist extension, and flexion. Option A: Conus medullaris Syndrome is caused by injury to the terminal aspect of the spinal cord, just proximal to the cauda equina. It characteristically presents with loss of sacral nerve root functions. Loss of Achilles tendon reflexes, bowel and bladder dysfunction, and sexual dysfunction may be observable. Option C: C3 to C4 contributes to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing. If C3 or C4 are involved, abnormal breathing or respiratory failure can occur. Option D: Neurogenic Shock results from high cervical injuries affecting the cervical ganglia, which leads to a loss of sympathetic tone. Loss of sympathetic tone results in a shock state characterized by hypotension and bradycardia.
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? A. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. B. Rapid Dilantin administration can cause cardiac arrhythmias. C. Dilantin should be mixed in dextrose in water before administration. D. Dilantin should be administered through an IV catheter in the client's hand.
Correct Answer: B. Rapid Dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. The drug is slowly administered intravenously directly into a large central or peripheral vein through an IV catheter less than 20 gauge, not exceeding a rate of 50 mg/minute. Option A: Therapeutic drug levels range from 10 to 20 mg/ml. Phenytoin displays its primary signs of toxicity on the nervous and cardiovascular systems. Overdose on oral phenytoin mainly causes neurotoxicity, whereas cardiovascular toxicity is the main side effect of parenteral administration. Option C: Dilantin shouldn't be mixed in solution for administration. However, because it's compatible with normal saline solution, it can be injected through an IV line containing normal saline. It requires dilution with sodium chloride. Crystals will form when diluted with dextrose solution. Option D: When given through an IV catheter hand, Dilantin may cause purple glove syndrome. "Purple glove syndrome" is a rare side effect that can accompany the intravenous administration of phenytoin. The worsening limb edema and discoloration appear to result from the crystallization of phenytoin within the blood. When there are extensive skin necrosis and limb ischemia, this can lead to amputations.
Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? A. Insert an indwelling urinary catheter to straight drainage. B. Schedule intermittent catheterization every 2 to 4 hours. C. Perform a straight catheterization every 8 hours while awake. D. Perform Crede's maneuver to the lower abdomen before the client voids.
Correct Answer: B. Schedule intermittent catheterization every 2 to 4 hours. Intermittent catheterization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Begin bladder retraining per protocol when appropriate (fluids between certain hours, digital stimulation of trigger area, contraction of abdominal muscles, Credé's maneuver). Option A: Begin intermittent catheterization program when appropriate. Intermittent catheterization may be implemented to reduce complications usually associated with long-term use of indwelling catheters. A suprapubic catheter may also be inserted for long-term management. Option C: Indwelling catheters may predispose the client to infection and are removed as soon as possible. Keep the bladder deflated by means of indwelling catheter initially. Indwelling catheter is used during acute phase for prevention of urinary retention and for monitoring output. Option D: Crede's maneuver is not used on people with spinal cord injury. Timing and type of bladder program depend on type of injury (upper or lower neuron involvement). Note: Credé's maneuver should be used with caution because it may precipitate autonomic dysreflexia.
Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? A. Absence of pain sensation in chest B. Spasticity C. Spontaneous respirations D. Urinary continence
Correct Answer: B. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. Spinal shock is a result of severe spinal cord injury. It usually requires high-impact, direct trauma that leads to spinal cord injury and spinal shock. The initial encounter with a patient that has spinal shock is usually under a trauma scenario. Option A: The absence of pain sensation in the chest doesn't apply to spinal shock. With high cervical injuries, the diaphragmatic function will be compromised, and these patients will necessitate early tracheotomy since they will be ventilator dependent. Deep vein thrombosis is excessively high in these patients. Option C: Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above. In spinal shock, there is a transient increase in blood pressure due to the release of catecholamines. This is followed by a state of hypotension, flaccid paralysis, urinary retention, and fecal incontinence. The symptoms of spinal shock may last a few hours to several days/weeks. Option D: The full spinal examination should include motor, sensory reflexes including bulbocavernosus reflex and anal wink reflex. Motor activity and strength decrease not only in the skeletal muscles but the motor activity of internal organs like bowel and bladder. This decrease leads to constipation and urinary retention.
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? A. To hasten wound healing. B. To immobilize the cervical spine. C. To prevent autonomic dysreflexia. D. To hold bony fragments of the skull together.
Correct Answer: B. To immobilize the cervical spine. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished. There are several uses for GWT, including the treatment of cervical spine fractures, patient positioning inside the operating room, and skeletal traction during spinal deformity surgery. Aside from GWT, different apparatuses have been utilized for skeletal traction, including Crutchfield's caliper, Cone's caliper, Blackburn's caliper, and halo traction. Option A: GWT have become popular in the United States due to their ease of use, and effectiveness in reducing cervical dislocations in a traumatic setting. Several advantages over previous traction devices include the lack of skin incisions, antiseptic instead of aseptic technique, and the lack of drill holes. Option C: Proper bladder and bowel care (ie, preventing fecal impaction, bladder distention) are mainstays in preventing episodes of autonomic dysreflexia. Regulation of the bladder routine via indwelling Foley catheter or intermittent catheterization and regular urologic follow-up is highly recommended for autonomic dysreflexia prevention. Option D: GWT has many advantages that have led to their increased popularity and usage. These include the relative ease of use, sterile technique, lack of incisions, reduced screw pullout, and elimination of burr holes.
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? A. A client with a brain injury. B. A client with a herniated nucleus pulposus. C. A client with a high cervical spine injury. D. A client with a stroke.
Correct Answer: C. A client with a high cervical spine injury. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia. The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the greater the severity of the cardiovascular dysfunction. The severity and frequency of autonomic dysreflexia episodes are also associated with the completeness of the spinal cord injury. Option A: The American Journal of Psychiatry published a study in 2015 that showed the prevalence of comorbidity of disorders among soldiers classified at T2 (3 months post-deployment) as experiencing a major depressive episode, PTSD, generalized anxiety disorder, or suicidality in the past 30 days went up from 12.9% to 16.8% at T3 (9 months post-deployment). Option B: Complications associated with nucleus pulposus herniation can result from the compression effect on the nerve root in severe cases resulting in motor deficit, in the cervical and thoracic spine there is also a risk of spinal cord compression in severe cases. These complications are relatively uncommon but should be considered and properly treated to avoid a permanent neurological deficit. Option D: Stroke complications can also impact a patient's prognosis. Common complications include pneumonia, deep vein thrombosis, urinary tract infections, and pulmonary embolism. However, patients who do not experience any complications within the first week tend to experience steady neurological improvement. The majority of patients experience the most improvement during the first 3 to 6 months after a stroke.
When discharging a client from the ER after head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best describes a lucid interval? A. An interval when the client's speech is garbled. B. An interval when the client is alert but can't recall recent events. C. An interval when the client is oriented but then becomes somnolent. D. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.
Correct Answer: C. An interval when the client is oriented but then becomes somnolent. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. The lucid interval following head trauma and unconsciousness is described classically in epidural hematomas. The historic emphasis placed on the lucid interval in cases of extradural hematoma has made this one of the best-remembered signs of the syndrome. Initial unconsciousness is thought to be due to the concussive effect of the blow to the head. The lucid period is the time required for the clot to grow to proportions great enough to produce compression of the brain. Option A: Garbled speech is known as dysarthria. Dysarthria is a motor speech disorder in which the muscles that are used to produce speech are damaged, paralyzed, or weakened. The person with dysarthria cannot control their tongue or voice box and may slur words. Option B: An interval in which the client is alert but can't recall recent events is known as amnesia. Amnesia is a dramatic form of memory loss. If you have amnesia you may be unable to recall past information (retrograde amnesia) and/or hold onto new information (anterograde amnesia). Option D: Warning symptoms or auras typically occur before seizures. Focal aware seizures (FAS) are sometimes called 'warnings' or 'auras' because, for some people, a FAS develops into another type of seizure. The FAS is therefore sometimes a warning that another seizure will happen (see focal to bilateral tonic-clonic seizures).
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? A. Assess full ROM to determine extent of injuries. B. Call for an immediate chest x-ray. C. Immobilize the client's head and neck. D. Open the airway with the head-tilt-chin-lift maneuver.
Correct Answer: C. Immobilize the client's head and neck. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. The airway doesn't need to be opened since the client appears alert and not in respiratory distress. The management of patients with head trauma should always consider C-spine motion restriction. Hold the neck immobile in line with the body, apply a rigid or semi rigid cervical collar, and (unless the patient is very restless) secure the head to the trolley with sandbags and tape. Option A: ROM would be contraindicated at this time. Cervical spine injury can be difficult to diagnose in the unconscious patient and should be assumed to be present until it can confidently be excluded. The patient should be positioned properly with the neck in neutral position and the head end of the bed elevated to 30°. This facilitates cerebral venous drainage. Option B: There is no indication that the client needs a chest x-ray. A tension pneumothorax is a life-threatening emergency which should be diagnosed clinically and treated promptly. An indwelling arterial cannula allows serial blood gas measurement and continuous recording of BP. Pulse oximetry is valuable for indirect measurement of how well the patient is being oxygenated. Option D: In addition, the head-tilt-chin-lift maneuver wouldn't be used until the cervical spine injury is ruled out. The priority in TBI must always be to secure, maintain, and protect a clear airway. Remove secretions and foreign bodies by manual extraction or suction, giving oxygen by mask (10-12 1/min).
A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? A. acetazolamide (Diamox) B. furosemide (Lasix) C. methylprednisolone (Solu-Medrol) D. sodium bicarbonate
Correct Answer: C. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren't indicated in this circumstance. Methylprednisolone and its derivatives, methylprednisolone acetate succinate, and methylprednisolone sodium, are intermediate-acting, synthetic glucocorticoids used mainly as anti-inflammatory or immunosuppressive agents. Methylprednisolone is five times more potent in its anti-inflammatory properties relative to hydrocortisone (cortisol), with minimal mineralocorticoid activities compared to the latter. Option A: Acetazolamide is a diuretic and carbonic anhydrase inhibitor medication that is used to treat several illnesses. Acetazolamide is a classic treatment option for glaucoma as it causes a reduction in the aqueous humor. As well, it is useful for the treatment of altitude sickness, because of its underlying mechanism of action. The medication works to excrete bicarbonate. Option B: The Food and Drug Administration (FDA) has approved the use of furosemide in the treatment of conditions with volume overload and edema secondary to congestive heart failure exacerbation, liver failure, or renal failure including the nephrotic syndrome. Option D: The main therapeutic effect of sodium bicarbonate administration is in increasing plasma bicarbonate levels, which are known to buffer excess hydrogen ion concentration, thereby raising solution pH to combat clinical manifestations of acidosis.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? A. Autonomic dysreflexia B. Hypervolemia C. Neurogenic shock D. Sepsis
Correct Answer: C. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. Option A: Autonomic dysreflexia occurs after neurogenic shock abates. Neurogenic shock is defined as the injury to the spinal cord with associated autonomic dysregulation. This dysregulation is due to a loss of sympathetic tone and an unopposed parasympathetic response. Neurogenic shock is most commonly a consequence of traumatic spinal cord injuries. Option B: Hypervolemia is indicated by rapid and bounding pulse and edema. The joint committee of the American Spinal Injury Association and the International Spinal Cord Society proposed the definition of a neurogenic shock to be general autonomic nervous system dysfunction that also includes symptoms such as orthostatic hypotension, autonomic dysreflexia, temperature dysregulation. Option D: Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate. Though neurogenic shock should be considered only after a hemorrhagic shock has been ruled out in a traumatic patient, the presence of vertebral fracture or dislocation raises the concern for a neurogenic shock. Bradyarrhythmia, hypotension, flushed warm skin are the classic signs associated with neurogenic shock.
While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? A. Autonomic dysreflexia B. Hemorrhagic shock C. Neurogenic shock D. Pulmonary embolism
Correct Answer: C. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Neurogenic shock is a devastating consequence of spinal cord injury (SCI), also known as vasogenic shock. Injury to the spinal cord results in a sudden loss of sympathetic tone, which leads to the autonomic instability that is manifested in hypotension, bradyarrhythmia, and temperature dysregulation. Option A: Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Autonomic dysreflexia is a condition that emerges after a spinal cord injury, usually when the injury has occurred above the T6 level. The higher the level of the spinal cord injury, the greater the risk with up to 90% of patients with cervical spinal or high-thoracic spinal cord injury being susceptible. Option B: Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. Hemorrhagic shock is due to the depletion of intravascular volume through blood loss to the point of being unable to match the tissues demand for oxygen. As a result, mitochondria are no longer able to sustain aerobic metabolism for the production of oxygen and switch to the less efficient anaerobic metabolism to meet the cellular demand for adenosine triphosphate. Option D: Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility. Pulmonary embolism (PE) occurs when there is a disruption to the flow of blood in the pulmonary artery or its branches by a thrombus that originated somewhere else.
A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? A. Bladder distension B. Neurological deficit C. Pulse ox readings D. The client's feelings about the injury
Correct Answer: C. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Maintain patent airway: keep head in neutral position, elevate head of bed slightly if tolerated, use airway adjuncts as indicated. Measure serial ABGs and pulse oximetry. Documents status of ventilation and oxygenation, identifies respiratory problems such as hypoventilation (low Pao2 and elevated Paco2) and pulmonary complications. Option A: Identify and monitor precipitating risk factors (bladder and bowel distension or manipulation; bladder spasms, stones, infection; skin/tissue pressure areas, prolonged sitting position; temperature extremes or drafts). Visceral distention is the most common cause of autonomic dysreflexia, which is considered an emergency. Treatment of acute episodes must be carried out immediately (removing stimulus, treating unresolved symptoms), then interventions must be geared toward prevention. Option B: Assess and document sensory function or deficit (by means of touch, pinprick, hot or cold, etc.), progressing from an area of deficit to a neurologically intact area. Changes may not occur during acute phase, but as spinal shock resolves, changes should be documented by dermatome charts or anatomical landmarks ("2 in above nipple line"). Option D: Although the other options would be necessary at a later time, observation for respiratory failure is the priority. Encourage expressions of sadness, grief, guilt, and fear among the patient, SO, and friends. Knowledge that these are appropriate feelings that should be expressed may be very supportive to the patient and SO.
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? A. "Clean the meatus from back to front." B. "Measure the quantity of urine." C. "Gently rotate the catheter during removal." D. "Clean the meatus with soap and water."
Correct Answer: D. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with a clean technique, using soap and water to clean the urinary meatus. Cleanse the perineal area and keep dry. Provide catheter care as appropriate. Decreases risk of skin irritation or breakdown and development of ascending infection. Option A: The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. Observe for cloudy or bloody urine, foul odor. Dipstick urine as indicated. Signs of urinary tract or kidney infection that can potentiate sepsis. Multistrip dipsticks can provide a quick determination of pH, nitrite, and leukocyte esterase suggesting the presence of infection. Option B: It isn't necessary to measure the urine. The nurse may measure residual urine via post void catheterization or ultrasound. Helpful in detecting the presence of urinary retention and effectiveness of the bladder training program. Note: Use of ultrasound is noninvasive, reducing the risk of colonization of the bladder. Option C: The catheter doesn't need to be rotated during removal. Keep the bladder deflated by means of an indwelling catheter initially. Begin intermittent catheterization program when appropriate. Intermittent catheterization may be implemented to reduce complications usually associated with long-term use of indwelling catheters.
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? A. Headache B. Lumbar spinal cord injury C. Neurogenic shock D. Noxious stimuli
Correct Answer: D. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decubitus ulcer, may cause autonomic dysreflexia. Dysregulation of the autonomic nervous system leads to an uncoordinated autonomic response that may result in a potentially life-threatening hypertensive episode when there is a noxious stimulus below the level of the spinal cord injury. In about 85% of cases, this stimulus is from a urological source such as a UTI, a distended bladder, or a clogged Foley catheter. Option A: A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia should be strongly suspected in any spinal cord injured patient with a lesion above T6 who complains of a headache. A blood pressure reading should be taken immediately, and corrective treatment starts if the patient's blood pressure is significantly elevated as most spinal cord injured patients have low blood pressure. Option B: Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Spinal cord injuries below T10 rarely result in autonomic dysreflexia because the splanchnic innervation remains intact and allows for compensatory parasympathetic dilation of the splanchnic vascular bed. The etiology is a spinal cord injury, usually above the T6 level. It is unlikely to occur if the level is below T10. The higher the injury level, the greater the severity of the cardiovascular dysfunction. Option C: Neurogenic shock isn't a cause of dysreflexia. The severity and frequency of autonomic dysreflexia episodes are also associated with the completeness of the spinal cord injury. Patients usually develop autonomic dysreflexia one month to one year after their injury. However, it has also been described in the first days or weeks after the original trauma. Objectively, an episode is defined as an increase in systolic blood pressure of 25 mm Hg.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? A. Elevate the client's legs. B. Put the client flat in bed. C. Put the client in Trendelenburg's position. D. Put the client in the high-Fowler's position.
Correct Answer: D. Put the client in the high-Fowler's position. Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. Sitting the patient upright and removing any tight clothing or constrictive devices will orthostatically help lower blood pressure by inducing pooling of blood in the abdominal and lower extremity vessels as well as removing any possible stimuli. Option A: If the trigger cannot be identified and initial maneuvers do not improve the systolic blood pressure below 150 mm Hg pharmacologic management should be initiated. Hypertension should be promptly corrected with agents that have a rapid onset but short duration of action. Option B: Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing a tetraplegic in a sitting position automatically lowers BP. Option C: Putting the bed in Trendelenburg's position places the client in a position that improves cerebral blood flow, worsening hypertension. Monitor BP frequently (every 3-5 min) during acute autonomic dysreflexia and take action to eliminate stimulus. Continue to monitor BP at intervals after symptoms subside.
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? A. Place the client flat in bed. B. Assess patency of the indwelling urinary catheter. C. Give one SL nitroglycerin tablet. D. Raise the head of the bed immediately to 90 degrees.
Correct Answer: D. Raise the head of the bed immediately to 90 degrees. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Elevate head of bed to 45-degree angle or place patient in sitting position. Lowers BP to prevent intracranial hemorrhage, seizures, or even death. Note: Placing tetraplegic in sitting position automatically lowers BP. Option A: Putting the client flat will cause the blood pressure to increase even more. Identify and monitor precipitating risk factors (bladder and bowel distension or manipulation; bladder spasms, stones, infection; skin/tissue pressure areas, prolonged sitting position; temperature extremes or drafts). Visceral distention is the most common cause of autonomic dysreflexia, which is considered an emergency. Treatment of acute episodes must be carried out immediately (removing stimulus, treating unresolved symptoms), then interventions must be geared toward prevention. Option B: The indwelling urinary catheter should be assessed immediately after the HOB is raised. Eliminate causative stimulus as able such as bladder, bowel, skin pressure (including loosening tight leg bands or clothing, removing abdominal binder or elastic stockings); temperature extremes. Removing noxious stimulus usually terminates the episode and may prevent more serious autonomic dysreflexia (in the presence of sunburn, topical anesthetic should be applied). Option C: Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia. Monitor BP frequently (every 3-5 min) during acute autonomic dysreflexia and take action to eliminate stimulus. Continue to monitor BP at intervals after symptoms subside. Aggressive therapy and removal of stimulus may drop BP rapidly, resulting in a hypotensive crisis, especially in those patients who routinely have low BP.
A client with a C6 spinal injury would most likely have which of the following symptoms? A. Aphasia B. Hemiparesis C. Paraplegia D. Tetraplegia
Correct Answer: D. Tetraplegia Tetraplegia occurs as a result of cervical spine injuries. Cervical injuries lead to the same deficits as thoracic injuries and, also, may result in loss of function of the upper extremities leading to tetraplegia. Injuries above C5 may also cause respiratory compromise due to loss of innervation of the diaphragm. Option A: Aphasia is an impairment to comprehension or formulation of language caused by damage to the cortical center for language. It can be caused by many different brain diseases and disorders; however, cerebrovascular accident (CVA) is the most common reason for a person to develop aphasia. Option B: Hemiparesis is weakness or the inability to move on one side of the body, making it hard to perform everyday activities like eating or dressing. Where the stroke occurred in the brain will determine the location of your weakness. Injury to the left side of the brain, which controls language and speaking, can result in right-sided weakness. Left-sided weakness results from injury to the right side of the brain, which controls nonverbal communication and certain behaviors. Option C: Paraplegia occurs as a result of injury to the thoracic cord and below. Paraplegia is a form of paralysis that mostly affects the movement of the lower body. People with paraplegia may be unable to voluntarily move their legs, feet, and sometimes their abdomen.
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? A. Absent corneal reflex. B. Decerebrate posturing. C. Movement of only the right or left half of the body. D. The need for mechanical ventilation.
Correct Answer: D. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. C3 to C4 contribute to breathing by controlling the muscles of the diaphragm. Patients with an injury in this area of the cervical spine can complain of difficulty breathing. Option A: Apart from the obvious physical complaints, neuropsychiatric symptoms noticeably vary out of proportion with the severity of the correspondent TBI. The patients who experience post-concussion syndrome may have somatic complaints like a headache, dizziness, cognitive impairment, and neuropsychiatric symptoms like anxiety, irritability, depression, and sleep disorders. Option B: Decerebrate posturing occurs with brain injuries, not spinal cord injuries. Decerebrate posturing can be seen in patients with large bilateral forebrain lesions with progression caudally into the diencephalon and midbrain. It can also be caused by a posterior fossa lesion compressing the midbrain or rostral pons. Option C: TBI may result in a decrease in short and long-term global health (physical and behavioral) and put them at an elevated risk for disability, pain, and handicap (i.e., difficulty with a return to work, maintaining peer networks.) Rehabilitation therapies like physical therapy, occupational therapy, speech-language therapy, and assistive devices and technologies may help to strengthen patients to perform their activities of daily living.
After a hypophysectomy, vasopressin is given IM for which of the following reasons? A. To treat growth failure. B. To prevent syndrome of inappropriate antidiuretic hormone (SIADH). C. To reduce cerebral edema and lower intracranial pressure. D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
Correct Answer: D. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy or removal of the pituitary gland, the body can't synthesize ADH. Initial management includes oral fluid replacement. However, in the event of unresolved DI, therapy is stepped up, ranging from fluid replacement with 5% dextrose to the administration of synthetic ADH analog, desmopressin. Intranasal desmopressin is the drug of choice for chronic cases of DI. Option A: Somatropin or growth hormone, not Vasopressin is used to treat growth failure. Childhood-onset is associated with decreased growth of all skeletal structures leading to dwarfism. Adult-onset HGH deficiency is less easily diagnosed as it has no single identifying feature that is pathognomonic. Typically adults have decreased skeletal muscle and increased fat mass in visceral tissue as well as decreased bone density and remodeling, which leads to osteoporosis. Option B: SIADH results from excessive ADH secretion. Syndrome of inappropriate antidiuretic hormone ADH release (SIADH) is a condition defined by the unsuppressed release of antidiuretic hormone (ADH) from the pituitary gland or non pituitary sources or it's continued action on vasopressin receptors. Option C: Mannitol or corticosteroids are used to decrease cerebral edema. Glucocorticoids have shown potential benefit in cerebral edema secondary to vasogenic edema but have limited utility in other forms of edema and should be avoided altogether in the face of trauma. Mannitol is the primary agent used at doses of 0.25 to 1 g/kg body weight and is thought to exert its greatest benefit by decreasing blood viscosity and to a lesser extent by decreasing blood volume.
