test 5 chpt 45 med surge

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."

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?

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

Which of the following types of skull fractures may be evident by Battle's sign?

Basilar

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

Body Temperature

A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

Bradycardia Bradypnea Hypertension

Which of the following is the earliest and most significant sign of increasing intracranial pressure

Change in level of consciousness (LOC)

3 cardinal signs of brain death?

Coma Absence of brain stem reflexes Apnea

A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?

Excessive urine output and decreased urine osmolality

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

Eye opening Verbal response Motor response

A nurse is assessing a client who has sustained a traumatic brain injury. The client's Glasgow Coma Score (GCS) is 15. Which assessment would the nurse most likely document? Select all that apply.

Eye opening response: spontaneous Best motor response: obeys command Best verbal response: oriented

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

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Flaccid

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:

Glasgow Coma Scale of 6

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?

Increased ICP is 12 mm Hg.

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

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

It allows for stabilization of the cervical spine along with early ambulation

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place the client in a sitting position.

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.

pt. with T2 injury in spinal shock- observe what assessment?

absence of reflexes along with flaccid extremities

pt. rapidly progressing toward brain death- what cardinal signs? select all

apnea coma absence of brain stem reflexes

pt. with SCI has nursing diagnosis of altered mobility- increases the risk of DVT- appropriate nursing interventions to prevent DVT?

applying thigh high elastic stockings

neurologic flow chart used in pts. with TBI-at what point in pts. care should nurse use flow chart?

as soon as the initial assessment is made

nurse implemented interventions aimed at facilitating family coping- how can nurse best facilitate?

assist the family in setting appropriate short term goals

nurse caring for critically ill pt. with autonomic dysreflexia- clinical manifestation?

bradycardia and hypertension

The nurse reviews the laboratory results for a client who has sustained a traumatic brain injury. Which lab result is considered critical and should be reported to the health care provider immediately?

serum magnesium of 1.1 mg/dL (0.45 mmol/L)

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

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:

she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

shivering

3 components of brain?

skull brain tissue blood and cerebral spinal fluid

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

spasticity

Pt. admitted to neurologic ICU with SCI- when assessing- nurse notes sudden depression of reflex activity in the spinal cord below level of injury- what should nurse suspect?

spinal shock

A nurse in a rehabilitation facility is coordinating the discharge of a client who is tetraplegic. The client, who is married and has two children in high school, is being discharged to home and will require much assistance. Who would the discharge planner recognize as being the most important member of this client's care team?

spouse

pt. being treated for SCI- advocating for removal of catheter- what principle should guide the care teams decision?

urinary retention can have serious consequences in pts. with SCI's

A client with a head injury is being assessed for altered level of consciousness (LOC) and increased intracranial pressure (ICP). The nurse understands that treatment for increased ICP will be initiated at a pressure greater than:

20mm/hg

The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client?

5 to 15 mm Hg

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

7

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80

The earliest sign of serious impairment of brain circulation related to increased ICP is:

A change in consciousness.

The nurse is caring for an 82-year-old client diagnosed with cranial arteritis. What is the priority nursing intervention?

Administer corticosteroids as ordered

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis?

Hypotension

A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?

Immediately

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

pt. admitted to neurologic ICU with SCI- pts. care plan- contractures can best be prevented by what action?

Initiating ROM exercises as soon as possible after the injury

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

Insertion of a nasogastric (NG) tube

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

Lethargy and Stupor

pt. admitted to neurologic ICU- with suspected diffuse axonal injury- primary neuroimaging diagnostic tool to evaluate brain structure?

MRI

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

Maintain a clear airway to ensure adequate ventilation

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness

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

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:

Severe TBI

The nurse is assessing a client with a confirmed spinal cord tumor. The client states, "I've been too embarrassed to tell anyone but, I have been awakened at night because I've wet the bed." It would be a priority for the nurse to further assess the client for which complication?

Spinal cord compression

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

Spinal shock

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

Vomits

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like the person in part B of the accompanying image. Which posturing is the patient exhibiting?

decerebrate

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

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting?

decorticate

pt. brought to ed after falling off roof- when fell she was knocked out- came to and seemed ok- now has severe headache and not feeling well- care team suspects epidural hematoma- which priority interventions?

emergency craniotomy

splints ordered for pt. at risk of foot drop- from SCI- splints are removed and reapplied?

every 2 hrs

nurse caring for pt. with SCI-pt. exhibiting early signs of disuse syndrome- nurse appropriate action?

increase the frequency of ROM exercises

Pt. admitted to neurologic ICU-C4 spinal cord injury- when writing plan of care-which nursing diagnosis should nurse prioritize in immediate care of pt.?

ineffective breathing patterns related to weakness of intercostal muscles

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

traction with weights and pulleys

pt. sustained nondepressed skull fracture- nursing care should include?

watchful waiting and close monitoring

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

young age alcohol abuse drug abuse

school nurse-giving presentation- on preventing SCI- prominent risk factors? select all

young age male gender alcohol or drug use

A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC?

By assessing according to the Glasgow Coma Scale (GCS)

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

Subdural hematoma

nurse reviewing trend of pts. scores on GCS- allows nurse to gauge what aspect of pts. status?

level of consciousness

To meet the sensory needs of a client with viral meningitis, the nurse should:

minimize exposure to bright lights and noise.

ED nurse called from EMS- 17 male who just sustained a SCI- most common cause of this type of injury?

motor vehicle accidents

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

Sweating

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear

nurse providing health education to pt with C6 spinal cord injury-pt. asks why autonomic dysreflexia is considered an emergency- nurses best answer?

The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?

Widened Pulse Pressure

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

ED nurse caring for pt. brought in by ambulance after sustaining fall- what physical assessment findings indicate basilar skull fracture?

bruising over the mastoid

nurse planning care- T1 SCI- diagnosis- risk for impaired skin integrity- how can nurse best address?

change the patients position frequently

pt. with SCI experienced several hypotensive episodes-how can nurse best address the risk for orthostatic hypotension?

monitor the pts. BP before and during position changes

Following SCI- pt. placed in halo traction-while performing pin site care- nurse noticed one pin came detached- what priority nursing?

notify the neurosurgeon of the occurrence

T2 spinal cord injury admitted- pt. exhibiting manifestations of neurogenic shock- nurses most appropriate action?

prepare for interventions to increase the patients BP