Intracranial Quiz

A patient suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first?

- Change in LOC

15. A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5

A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

1.6 (125/2=62.5 per mL) (100/62.5=1.6)

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

7

The child is having a seizure activity displayed as suddenly dropping a cup of soda but not falling. Her face looked blank and the eyelids were twitching. The child does not recall anything after the seizure denies an aura and was not incontinent. What term would best describe this seizure?

Absence Seizure

The nurse witnesses a patient with a seizure disorder as the patient suddenly jerks the arms and legs, falls to the floor, and then regains consciousness immediately. The first initial action by the nurse should be:

Assess the patient for a possible head injury

Which one of the following signs and symptoms would be an indication of increased intracranial pressure in infants?

Bulging fontanels

23. Which type of brain injury has occurred if the patient may be aroused with effort, but soon slips back into unconsciousness?

Contusion i. A patient with a contusion may be aroused with effort but soon slips back into unconsciousness. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brain stem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

The nurse notes in the patient's medical history that the patient has a positive Romberg test. Which diagnosis is appropriate?

Risk for falls related to dizziness or weakness

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

T6

19. A 65-year-old client was hit in the head with a ball and knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?

a. Acute i. Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

3. Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)?

a. Apply elastic stockings to lower extremities

11. You are a neuro trauma 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?

a. Autonomic dysreflexia i. Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsidesautonomic dysreflexia develops in individuals with a neurologic level of spinal cord injury at or above the sixth thoracic vertebral level (T6). Autonomic dysreflexia causes an imbalanced reflex sympathetic discharge, leading to potentially life-threatening hypertension.

24. 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 describes Battle's sign?

a. Ecchymosis over the mastoid

27. A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?

a. Ineffective breathing pattern

4. The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury?

a. It results from initial damage to the brain from the traumatic event

28. A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?

a. Look for signs of increased intracranial pressure

7. 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?

a. Maintain a diet for the client that is high in protein, vitamins, and calories. i. To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.

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

a. Motor vehicle crashes

13. A 67-year-old client who was involved in a motor-vehicle collision is brought to the emergency department. After examination and diagnostics, the neurosurgeon diagnoses an epidural hematoma and orders that the client be prepared for surgery. In preparing the client for surgery, which of the following would be the least likely intervention you would expect?

a. Preoperative sedation

10. 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?

a. Risk for injury

1.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?

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

25. A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

small amount of yellow drainage at the left pin insertion site

26. A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?

a. Basilar i. Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture. A simple (linear) fracture is a break in the continuity of the bone. A comminuted fracture refers to a splintered or multiple fracture line.

30. At which level of cord injury does a patient have full head and neck control?

a. C5 i. At level C5, there is full head and neck control. At C1 there is little or no sensation or control of the head and neck. At C2 to C3 there is head and neck sensation and some neck control. At C4 there is good head and neck sensation and motor control

20. A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

a. Risk for injury related to neurologic deficit

2.Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane?

a. Subdural hematoma

31. 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. Epidural Hematoma i. 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.

12. Which of the following is not a manifestation of Cushing's Triad?

a. Tachycardia i. Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad

14. A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus?

a. Take daily weights. i. A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process

Neurological testing of the patient by the nurse indicates impaired functioning of the left Glossopharyngeal nerve (CN IX) and the Vagus nerve (CN X) Based on these findings the nurse plans to:

Withhold oral fluids or foods

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

a. Racoon's eyes and Bettle sign i. A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function.

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

a. Absence of reflexes along with flaccid extremities i. During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.

18. While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Upon his arrival via squad at the ED where you practice nursing, he regained consciousness within an hour. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?

a. Concussion i. 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. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.

22. 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?

a. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. i. Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion

29. When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following?

a. Decerebrate i. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

5. A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

a. Vomits i. Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in the patient with a concussion is an expected abnormal observation. However, a severe headache should be reported or treated immediately. Weakness of one side of the body should be reported or treated immediately. Difficulty in waking the patient should be reported or treated immediately.