neuro

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

7

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

Absence of reflexes along with flaccid extremities

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?

An area of bruising over the mastoid bone (behind ear)

A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring?

Applying thigh-high elastic stockings

Which positions is used to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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?

Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.

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?

Decerebrate

After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position?

Flat, except for logrolling as needed

A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?

GCS

The nurse is caring for a patient with an altered LOC. What is the first priority of treatment for this patient?

Maintenance of a patent airway

A nurse is assessing a newly admitted client with meningitis. Which of the following findings in this client is most likely?

Positive Brudzinski's sign (Severe neck stiffness causes a patient's hips and knees to flex when the neck is flexed)

An 18-year-old man is admitted witha closed head injury that he sustained in a motorcycle accident. He has been showing an upward trend in his ICP measurements. Which of the following interventions should be the first action that the nurse takes?

Reposition the patient to avoid neck flexion

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

T6

Which is the earliest sign of increasing intracranial pressure?

change in LOC

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

concussion

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

lethargy

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP?

lethargy and stupor

A client with neurological infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?

restrict fluid and hydration

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

spinal shock

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

administer stool softener

The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?

airway clearance

You are a neurotrauma 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?

autonomic dysreflexia

The nurse notices clear fluid draining from the nose of a patient who sustained a head injury 2 hours ago. This may indicate the presence of what condition?

basal skull fracture

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temperature

Which interventions should the nurse's plan of care include to help prevent autonomic dysreflexia in a patient with SCI? Select all that apply a Check for fecal impactions b Monitor BP for hypotension c Check urinary drainage system for Obstruction d Monitor Bowel movements e Instruct pt to wear a medical bracelet

de

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to

dehydrate the brain and reduce cerebral edema.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

subdural hematoma

Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?

tachycardia