Ch 68 exam 2

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client?

Apply an external urinary sheath catheter

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

Contusion

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoon's eyes and Battle sign

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.

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

7 Explanation: A score between 3 and 8 is generally accepted as indicating a severe head injury.

A client with quadriplegia is in spinal shock. What finding should the nurse expect?

Absence of reflexes along with flaccid extremities

A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?

Basilar

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skill fracture. Which of the following correctly decribes Battle's sign?

Ecchymosis over the mastoid

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

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 Venous pooling Tachypnea Hypothermia

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

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 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?

Keep the client's neck in a neutral position (no flexing).

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

Paresthesia

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

Spinal shock

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

T6

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

Venous pooling in the extremities Bradycardia Warm skin

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.

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of?

Basilar skull fracture

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?

Burr holes

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5

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?

Epidural hematoma

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

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?

Monitoring the patency of an indwelling urinary catheter

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?

acute

While snowboarding, a 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?

concussion

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?

An area of bruising over the mastoid bone

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?

An intracerebral hematoma

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.

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

The Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents

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

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician.

A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

A Glasgow Coma Scale (GCS) score of 7 or less is generally interpreted as

coma.

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client?

Lung auscultation and measurement of vital capacity and tidal volume

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?

Maintain a diet for the client that is high in protein, vitamins, and calories.

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)?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

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.

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

Young age Alcohol use Drug abuse

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

Subdural hematoma

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?

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

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply.

Offer encouragement as the client makes progress. Involve the client actively in self care.

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?

Contusion