week 11

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? Verapamil (Calan) Metoprolol (Lopressor) Amiodarone (Cordarone) Captopril (Coreg)

Verapamil (Calan)

Which are possible long-term complications of spinal cord injury? Select all that apply. respiratory arrest areflexia autonomic dysreflexia respiratory infection

autonomic dysreflexia respiratory infection

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? 8 to 15 mm Hg 0 to 10 mm Hg 20 to 30 mm Hg 25 to 40 mm Hg

0 to 10 mm Hg

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? Being an athlete Male gender Young age Alcohol/drug use

Being an athlete

The causes of acquired seizures include what? (Mark all that apply.) Cerebrovascular disease Metabolic and toxic conditions Hypernatremia Brain tumor Drug and alcohol withdrawal

Cerebrovascular disease Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Cloudy cerebral spinal fluid Pain and stiffness of the extremities Purpura of hands and feet Low white blood cell (WBC) count Low red blood cell (RBC) count Low antidiuretic hormone (ADH) levels

Cloudy cerebral spinal fluid Purpura of hands and feet

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

Contusion

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. Stiff neck Generalized pain Glasgow Coma Scale of 15 Elevated systolic blood pressure Brisk pupil response Wide pulse pressure

Elevated systolic blood pressure Wide pulse pressure

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? Epidural Subdural Intracerebral Contusion

Epidural

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? Decerebrate Decorticate Flaccid Rigid

Flaccid

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Hemiparesis Tachypnea Decreased reactivity of the pupils Bradycardia Hypotension Coma

Hemiparesis Bradycardia Decreased reactivity of the pupils Coma

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. Hypertension Tachycardia Fever Diaphoresis Nasal congestion

Hypertension Diaphoresis Nasal congestion

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypotension Tachycardia Venous pooling Diaphoresis Tachypnea Hypothermia

Hypotension Venous pooling Tachypnea Hypothermia

A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? Immediate craniotomy An order for a head computed tomography scan Intubation and mechanical ventilation IV administration of propofol

Immediate craniotomy

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? Fluid volume deficit Risk for infection Ineffective cerebral tissue perfusion Risk for injury

Ineffective cerebral tissue perfusion

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

Neurologic examination

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity Excessive urine output and serum hyponatremia

Oliguria and serum hyponatremia

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Placing him on mechanical ventilation Performing a lumbar puncture Elevating the head of his bed

Performing a lumbar puncture

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? Diarrhea Placing the client in a sitting position Placing a blanket over the client Voiding

Placing a blanket over the client

What drug, prescribed for Parkinson's disease, has neuroprotective properties? Amantadine (Symmetrel) Selegiline (Eldepryl) Bromocriptine (Parlodel) Levodopa (Larodopa)

Selegiline (Eldepryl)

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents

To avoid impeding venous outflow

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Venous pooling in the extremities Bradycardia Warm skin Tachycardia Profuse bilateral sweating

Venous pooling in the extremities Bradycardia Warm skin

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: loss of the sensation of pain and temperature on the side opposite the injury. loss of motor power and sensation in the upper extremities. preservation of a sense of touch below the level of the lesion. loss of motor power, pain, and temperature sensation below the level of the lesion.

loss of motor power and sensation in the upper extremities.

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? The client with an open head injury The client with a basilar fracture The client with a concussion The client with a coup injury

The client with a basilar fracture

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? Epidural hematoma Acute subdural hematoma Chronic subdural hematoma Grade 1 concussion

Epidural hematoma

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? Lorazepam (Ativan) Midazolam (Versed) Phenobarbital Propofol (Diprivan)

Propofol (Diprivan)

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? 6 to 8 hours 18 to 36 hours 12 to 24 hours 48 to 72 hours

18 to 36 hours

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? Extradural hematoma Epidural hematoma Subdural hematoma Intracranial hematoma

Epidural hematoma

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

Respiratory arrest Spinal shock

Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP? Pupils are equal and normally reactive. Pupils are unequal in diameter. Pupils are showing progressive dilation. Pupils are fixed and dilated.

Pupils are showing progressive dilation.