Chapter 39: Caring for Clients with Head and Spinal Cord Trauma

A neurologic flow chart is often used to document the care of a client with a traumatic brain injury. At what point in the client's care should the nurse begin to use a neurologic flow chart?

As soon as the initial assessment is made

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

A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?

Bradycardia and hypertension

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?

Risk for injury

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?

Widened pulse pressure

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.

Young age Male gender alcohol and drug use.

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

The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping?

Assist the family in setting appropriate short-term goals.

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action?

Initiating (ROM) exercises as soon as possible after the injury

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:

Leakage of cerebrospinal fluid (CSF)

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

Maintain a clear airway to ensure adequate ventilation.

Following a spinal cord injury a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?

Notify the neurosurgeon of the occurrence.

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

Prepare for interventions to increase the client's BP.

A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is:

a result of venous bleeding into the space below the dura.

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

Motor vehicle crashes

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

Splints have been prescribed for a client who is at risk of developing footdrop following a spinal cord injury. The nurse should remove and reapply the splints when?

Every 2 hours

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

Look for signs of increased intracranial pressure

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injury?

Pad the side rails of the client's bed.

Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image?

To confirm a skull fracture

Which of the following is a sign of increasing ICP?

Widening pulse pressure

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse's best answer?

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

The nurse is caring for a client following a head injury. The nurse understands that the client is at risk for posttraumatic seizures. A seizure classified as early occurs within which time frame?

1 to 7 days of injury

An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?

Maintain the patency of the patient's airway.

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension?

Monitor the client's BP before and during position changes.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

Motor vehicle accidents

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

Perform passive ROM exercises as prescribed.

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

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

A client was hit in the head with a ball and knocked unconscious. Diagnostic testing determined that the client suffered a subdural hematoma with moderate symptoms. As the client is admitted to the ICU for observation, what would the neurologist order? Select all that apply.

ICP monitoring

An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

Motor vehicle accidents

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 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?

Propofol (Diprivan)

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

Absence of reflexes along with flaccid extremities

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

Absence of reflexes along with flaccid extremities

Paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

Administer benzodiazepines on a PRN basis.

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this?

Baclofen

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

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 nurse responds to the call light of a client who has had a cervical diskectomy earlier in the day. The client states that she is having severe pain that had a sudden onset. What is the nurse's most appropriate action?

Call the surgeon to report the client's pain.

A nurse is planning discharge education for a client who underwent a cervical diskectomy. What strategies would the nurse assess that would aid in planning discharge teaching?

Care of the cervical collar

A halo sign is indicative of which of the following complication of brain injury?

Cerebrospinal fluid (CSF) leak

A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc?

Have the client lie on the back and lift the leg, keeping it straight.

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:

Increased intracranial pressure (ICP)

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?

Ineffective breathing patterns related to weakness of the intercostal muscles

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

T6

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

Temperature increase from 98.0°F to 99.6°F

A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

Watchful waiting and close monitoring