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

17. The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A. The client has cerebral spinal fluid (CSF) leaking from the ear. B. The client has ecchymosis in the periorbital region. C. The client has an elevated temperature. D. The client has serous drainage from the nose.

ANS: A Rationale: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.

28. The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used? A. A cervical collar B. Bandages and tape C. A firm mattress D. Traction equipment

ANS: A Rationale: A C4 injury is in the cervical spine region. A herniated cervical disk is treated conservatively (not surgically) by immobilizing the cervical spine with a cervical collar. Dressing supplies are not needed unless there is a wound. A firm mattress is appropriate for a lumbar herniation. Traction equipment is not used on cervical vertebrae.

30. The nurse is caring for a client who has undergone cervical laminectomy surgery. Which nursing intervention(s) is included in the postoperative plan of care? Select all that apply. A. Monitor vital signs. B. Report an inability to void or an output of less than 8 oz (240 mL) in 8 hours. C. Instruct on coughing and deep breathing exercises. D. Perform side-to-side range-of-motion exercises of the head and neck. E. Perform a neurovascular assessment below the area of the surgery. F. Examine dressing for CSF leakage or bleeding.

ANS: A, B, E, F Rationale: When planning care for a client who has undergone surgery for cervical nerve root decompression, the nurse should include monitoring vital signs, reporting on fluid intake and output, instruction on deep breathing exercises, performing neurovascular assessment below the area of the surgery, and examining the dressing for CSF leakage or bleeding. The nurse should not have the client perform coughing exercises, because these increase pressure within the spinal canal. The nurse should instruct the client to avoid side-to-side rotation of the head for the client with cervical nerve compression and should not perform side-to-side range of motion exercises of the head and neck.

14. A nurse is reviewing a CT scan of the brain, which shows 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? A. Symptoms will evolve over a period of 1 week. B. Monitoring is needed as rapid neurologic deterioration may occur. C. The crash cart with defibrillator is kept nearby. D. Bleeding continues into the intracerebral area.

ANS: B Rationale: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

10. The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? A. Acetaminophen may be administered for aches. B. Observe for any signs of behavioral changes. C. A light meal may be eaten if desired. D. Follow up with regular physician is encouraged.

ANS: B Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.

2. 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? A. Extradural hematoma B. Epidural hematoma C. Subdural hematoma D. Intracranial hematoma

ANS: B Rationale: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.

16. The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first? A. The client with an open head injury B. The client with a basilar fracture C. The client with a concussion D. The client with a coup injury

ANS: B Rationale: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.

26. A middle-aged client has scheduled a sick visit to the physician's office, reporting symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and shows potential causes of the pain. Which area of the drawing would the nurse emphasize? A. Spinal cord pathway B. Nucleus pulposus C. Bony vertebrae D. Associated musculature

ANS: B Rationale: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.

15. 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? A. The client has periorbital edema and ecchymosis. B. 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. C. The client's level of consciousness has improved. D. The client prefers to rest in the semi-Fowler's position.

ANS: B Rationale: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.

13. A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? A. The client is a heart transplant recipient. B. The client's medications include warfarin (Coumadin). C. The client is HIV positive. D. The client has a history of concussions from playing hockey.

ANS: B Rationale: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.

23. The nurse is caring for a female client who is newly paraplegic. The client and the client's spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful? A. Adoption is an option to complete your family but not put your life in jeopardy. B. Conception is not impaired, the birth process is determined with the health care provider. C. Birth via surrogate is best because your baby can be implanted in another woman. D. Sterilization is best; it would be difficult to care for a baby in your condition.

ANS: B Rationale: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.

27. 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? A. Sciatic nerve pain B. Herniation C. Paresthesia D. Paralysis

ANS: C Rationale: A client reports numbness and tingling in an area is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.

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

ANS: C Rationale: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.

20. The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? A. Numbness and tingling B. Respiratory pattern C. Pulse and blood pressure D. Pain level

ANS: C Rationale: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.

12. The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? A. The client with history of seizures B. The client who was in a bike accident last summer C. The client who played soccer in college D. The client whose father has Parkinson's disease

ANS: C Rationale: The client who has history of playing many years of a physical sport such as soccer and use the head to redirect the ball may have had years of injury to the brain. When concussions occur repetitively, even though they may have not shown injury at that time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy, which can produce neurodegeneration, will need specialized care. The client who has a history of seizures may have no brain injury. The client who was in a previous accident may have had injury, but it is not of a repetitive nature. The client with a father who has Parkinson's disease will have regular follow-up care.

29. The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious, stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain?" The nurse is most correct to turn the teaching to which surgical procedure? A. A discectomy B. A laminectomy C. A spinal fusion D. Aggressive traction

ANS: C Rationale: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A discectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option.

5. The nurse is caring for a client with impaired physical mobility who has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in this client? A. Provide a well-balanced diet. B. Position the client. C. Keep the client hydrated. D. Help the client perform exercises.

ANS: C Rationale: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony.

3. The nurse is caring for a client with a head injury after a fall. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid? A. Change in the level of consciousness (LOC) B. Signs of increased intracranial pressure (IICP) C. Halo sign D. Swelling

ANS: C Rationale: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage.

4. 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? A. Cervical collar B. Cast C. Traction with weights and pulleys D. Turning frame

ANS: C Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

22. The nurse is caring for a client with paralysis as a result of a spinal cord injury. When planning care related to the musculoskeletal system, which immediate complication(s) should the nurse consider? Select all that apply. A. Calcium depletion B. Contractures C. Respiratory arrest D. Spinal shock E. Autonomic dysreflexia

ANS: C, D Rationale: Spinal shock is an immediate complication of spinal cord injury, and is characterized by immediate loss of all cord functions below the point of injury. When planning care for clients with a spinal cord injury, the nurse should consider immediate complications including respiratory arrest and spinal shock. Calcium depletion, contractures, and autonomic dysreflexia are all long-term complications of spinal cord injury leading to paralysis.

25. A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of stem cell transplantation therapy. Which statement(s) should the nurse include in the teaching? Select all that apply. A. "Cells in the spinal cord may regenerate spontaneously when injured." B. "Stem cells can cause the damaged spinal nerves to repair themselves." C. "Stems cells can be harvested from an individual's own bone marrow." D. "Harvested stem cells can be reimplanted into the area surrounding the injury." E. "Stem cells can replace the damaged nerve cells when they are transplanted."

ANS: C, D, E Rationale: When teaching the client about the benefits of stem cell transplantation therapy, the nurse should explain how stem cells are used to treat a spinal cord injury. In particular, the education should emphasize that stem cells are harvested from the client's own bone marrow and can be reimplanted into the area surrounding the injury, replacing the damaged nerve cells when they are transplanted. The spinal cord loses the ability to regenerate when injured, and stem cells replace the injured spinal nerves rather than causing them to repair themselves, so the nurse would be incorrect to include these statements when discussing the therapy with the client.

6. A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be? A. "A concussion is a blow to the head that bruises the brain." B. "A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull." C. "A concussion is a blow to the head that is minor and has no real consequences." D. "A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

ANS: D Rationale: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. The other options are incorrect because they give incorrect information to the mother.

9. The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication? A. Understand that headaches are uncommon. B. You can cover the incision with your hair. C. You can expect swelling above the incision. D. Expect sensory changes, such as hearing a clicking sound, around the bone flap.

ANS: D Rationale: In addition, the nurse must provide the following verbal and written instructions: Watch for signs of intracranial bleeding and infection (expect swelling around the eye and below the incision). Expect sensory changes such as hearing a "clicking" sound around the bone flap, which will disappear as healing takes place. Understand that headaches also are common, but notify the surgeon if a mild analgesic such as acetaminophen fails to relieve them. Care for the surgical site as directed by the physician. Some recommendations include keeping the incision clean, avoiding scrubbing the incision, securing remaining hair away from the incision, resuming shampooing the hair when the staples or sutures are removed, and wearing a hat when outside to avoid sunburn until hair growth resumes. Maintain safety precautions at home, including ambulating only with assistance and ensuring well-lit and clutter- free rooms. Do not drive until the risk of seizures has been eliminated. Engage in exercises that promote strength and endurance. Use techniques to ensure bowel and bladder elimination. Follow feeding and/or nutritional suggestions. Keep follow-up appointments for measuring anticonvulsant blood levels, electroencephalograms, and continued medical care and evaluation. This information is usually given to the client on a take-home instruction sheet.

8. When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A. Extreme thirst B. Intake and output C. Nutritional status D. Body temperature

ANS: D Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.

21. The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? A. Autonomic nervous system B. Central nervous system C. Peripheral nervous system D. Sympathetic nervous system

ANS: D Rationale: The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates "feed and breed" functions. The central and peripheral nervous system is a component of the sympathetic nervous system.

24. The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae. From which location will bone be taken for the fusion? A. Iliac crest B. Floating rib C. Femur D. Mandible

ANS: A Rationale: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.

7. The nurse suspects that a newly admitted client is in spinal shock. What is a symptom(s) of spinal shock? Select all that apply. A. Bladder distention B. Poikilothermia C. Loss of hunger sensation D. Circulatory failure E. No perspiration below the level of the injury

ANS: A, B, E Rationale: In addition to paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. If the level of injury is in the cervical or upper thoracic region, respiratory failure can occur. Bowel and bladder distention develop. The client does not perspire below the level of injury, which impairs temperature control. The client manifests with poikilothermia, body temperature of the environment. Symptoms of spinal shock do not include loss of hunger sensation or circulatory failure.

19. The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders? A. The second cervical vertebrae B. The first thoracic vertebrae C. The seventh thoracic vertebrae D. The first lumbar vertebrae

ANS: B Rationale: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.

18. The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate? A. Edema to the head and a blackened eye B. Edema to the head with a large scalp laceration C. Edema to the head with fixed pupils D. Edema to the head with bruising of the mastoid process

ANS: D Rationale: Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

11. The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of the accident. The nurse provides all details to the next shift and is most accurate to report which type of injury? A. Coup injury B. Contusion C. Head injury D. Contrecoup injury

ANS: D Rationale: The nurse most accurately reports a contrecoup injury because the client has this type of dual brain injury. The client has experienced not only a direct strike to the brain but the brain ricochets in the skull to the opposite side causing damage and inflammation at that location as well. The client experienced a head injury, which is a general term. The injury is a contusion because it is more serious than a concussion and leads to structural injury to the brain. It is inaccurate to report a coup injury because this reveals injury to the brain itself from a direct strike to the head.