Management of Patients with Neurologic Trauma

Which Glasgow Coma Scale is indicative of severe head injury? A. 7 B. 9 C. 11 D. 13

A. 7

The most important nursing priority of treatment for a patient with an altered LOC is to: A. Maintain a clear airway to ensure adequate ventilation B. Position the patient to prevent injury and ensure dignity C. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain D. Prevent dehydration and renal failure by inserting an IV line for fluids and medications

A. Maintain a clear airway to ensure adequate ventilation

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 process and clear fluid from the ears. What type of skull fracture is this indicative of? A. Temporal skull fracture B. Basilar skull fracture C. Frontal skull fracture D. Occipital skull fracture

B. Basilar skull fracture

Which of the following is the earliest sign of increasing intracranial pressure (IICP)? A. Restlessness B. Change in level of consciousness (LOC) C. Pupil changes D. Seizures

B. Change in level of consciousness (LOC)

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A. Intracerebral B. Subdural C. Epidural D. Cerebral

B. Subdural

A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Hyperreflexia along with spastic extremities B. Spasticity of all four extremities C. Absence of reflexes along with flaccid extremities D. Positive Babinski's reflex along with spastic extremities

C. Absence of reflexes along with flaccid extremities

A client has hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent tests, it was determine that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? A. Chronic B. Intracerebral C. Acute D. Subacute

C. Acute

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. Assess pupillary response frequently B. Reposition the client frequently C. Take daily weights D. Assess vital signs frequently

C. Take daily weights

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' posturing as which of the following? A. Decorticate B. Normal C. Flaccid D. Decerebrate

D. Decerebrate

Which is the most common cause of spinal cord injury (SCI)? A. Acts of violence B. Falls C. Sports-related injuries D. Motor vehicle crashes

D. Motor vehicle crashes

Which condition occurs when blood collects between the dura batter and arachnoid membrane? A. Intracerebral hemorrhage B. Epidural hematoma C. Extradural hematoma D. Subdural hematoma

D. Subdural hematoma

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? A. L4 B. T10 C. S2 D. T6

D. T6

Which activities would the client with T4 spinal cord injury be able to perform independently? (Select all that apply.) A. Ambulating B. Writing C. Breathing D. Eating E. Transferring to a wheelchair

B. Writing C. Breathing D. Eating E. Transferring to a wheelchair

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 probably sign of which type of skull fracture? A. Comminuted B. Simple C. Basilar D. Depressed

C. 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? A. Hypophysectomy B. Application of Halo traction C. Burr holes D. Insertion of Crutchfield tongs

C. Burr holes

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign? A. Drainage of cerebrospinal fluid from the nose B. Ecchymosis over the mastoid C. Drainage of cerebrospinal fluid from the ears D. Bruising under the eyes

B. Ecchymosis over the mastoid

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? A. Symptoms will evolve over a period of 1 week B. Bleeding continues in the intracerebral area C. Monitoring is needed as rapid neurologic deterioration may occur D. The crash cart with defibrillator is kept nearby

C. Monitoring is needed as rapid neurologic deterioration may occur

Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Intracerebral hemorrhage B. Subdural hematoma C. Epidural hematoma D. Extradural hematoma

B. Subdural hematoma

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? A. Wait for the family members to approach with questions B. Reassure them that progress will be made, but it takes time C. Provide factual information and emotional support D. Allow family members distance and space to deal with the changes to the client

C. Provide factual information and emotional support