Chapter 68: Management of Patients With Neurologic Trauma 4

Suction the airway.

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

Lung auscultation and measurement of vital capacity and tidal volume

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?

Glasgow Coma Scale of 6

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:

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

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:

Monitoring is needed as rapid neurologic deterioration may occur.

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?

Edema to the head with bruising of the mastoid process

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate?

Ineffective airway clearance related to brain injury

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

severe hypertension, slow heart rate, pounding headache, sweating

Which are characteristics of autonomic dysreflexia?

Maintain cerebral perfusion pressure from 50 to 70 mm Hg

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)?

Insertion of a nasogastric tube

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?