Neuro and SCI
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to: insert an indwelling urinary catheter. use a condom catheter instead of an invasive one. place the client on fluid restrictions. increase the frequency of the catheterizations.
increase the frequency of the catheterizations.
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned like part B of the accompanying image. Based on this initial observation, what would the nurse predict about this patient's prognosis? (dece) poor good fatal excellent
poor
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: prevent respiratory alkalosis. lower arterial pH. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg. promote carbon dioxide elimination.
promote carbon dioxide elimination.
The Monro-Kellie hypothesis explains nonresponse of the brain to the environment. why the client is awake but lacks consciousness, without cognitive or affective mental function. the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. the dynamic equilibrium of cranial contents.
the dynamic equilibrium of cranial contents.
When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea with loud respirations, and systolic hypertension. To what complication can the nurse relate the change in the client's vital signs? Development of encephalitis Increased intracranial pressure Status epilepticus Impending shock
Increased intracranial pressure
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)? Encouraging oral fluid intake Administering a stool softener as ordered Elevating the head of the bed 90 degrees Suctioning the client once each shift
Administering a stool softener as ordered
The nurse is caring for a client whose recent health history includes an altered LOC. What should be the nurse's first action when assessing this client? Assessing the client's verbal response Assessing the client's response to pain Assessing the client's ability to follow complex commands Assessing the client's judgment
Assessing the client's verbal response
The nurse is caring for a client in the ICU who has a brain stem herniation and who is exhibiting an altered level of consciousness. Monitoring reveals that the client's mean arterial pressure (MAP) is 60 mm Hg with an intracranial pressure (ICP) reading of 5 mm Hg. What is the nurse's most appropriate action? Participate in interventions to increase cerebral perfusion pressure (CPP). Position the client the high Fowler position as tolerated. Prepare the client for craniotomy. Administer osmotic diuretics as prescribed.
Participate in interventions to increase cerebral perfusion pressure (CPP).
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? Complaints of headache and lack of pupillary response Mental confusion and pupillary changes Loss of gag reflex and mental confusion Decerebrate posturing and loss of corneal reflex
Decerebrate posturing and loss of corneal reflex
A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with a severe head injury. Upon entering the room, the nurse observes that the patient is positioned like part A of the accompanying image. Which posturing is the patient exhibiting? Tonic clonic Decorticate Decerebrate Flaccidity
Decorticate
The nurse is caring for a client with a brain tumor. What drug would the nurse expect to be prescribed to reduce the edema surrounding the tumor? Solumedrol Dexamethasone Furosemide Dextromethorphan
Dexamethasone
Which activity should be avoided in clients with increased intracranial pressure (ICP)? Position changes Minimal environmental stimuli Enemas Suctioning
Enemas
The nurse is caring for a client with a traumatic brain injury and experiencing increased intracranial pressure. The nurse has administered mannitol, an osmotic diuretic, as ordered. This medication promotes the shift of fluid from the intracellular to the intravascular compartment. Therefore, it is necessary for the nurse to continually assess for which of the following? Heart failure Kidney failure Pancreatitis Diabetes insipidus
Heart failure
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Coma Hemiparesis Bradycardia Hypotension Decreased reactivity of the pupils Tachypnea
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma
The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring? Increased ICP Increase in cerebral perfusion pressure Exacerbation of uncontrolled hypertension Infection
Increased ICP
A nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring? Infection High blood pressure Coma Apnea
Infection
A client has a poor prognosis after being involved in a motor vehicle accident resulting in a head injury. As the client's ICP increases and condition worsens, the nurse knows to assess for indications of approaching death. These indications include which of the following? Loss of brain stem reflexes Signs of internal bleeding Dry mucous membranes Hemiplegia
Loss of brain stem reflexes
After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Elevating the head of his bed Placing him on mechanical ventilation Performing a lumbar puncture
Performing a lumbar puncture
Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? Placing the client in a sitting position Voiding Placing a blanket over the client Diarrhea
Placing a blanket over the client
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? Hypertension and narrowing pulse pressure Hypotension and bradycardia Rising blood pressure and bradycardia Hypotension and tachycardia
Rising blood pressure and bradycardia
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following health care provider prescriptions: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To prevent flexion contractures To prevent aspiration of stomach contents To decrease cerebral arterial pressure To avoid impeding venous outflow
To avoid impeding venous outflow
Which are possible long-term complications of spinal cord injury? Select all that apply. autonomic dysreflexia respiratory arrest respiratory infection areflexia
autonomic dysreflexia respiratory infection
Which term refers to the shifting of brain tissue form an area of high pressure to an area of low pressure? Monro-Kellie hypothesis Autoregulation Herniation Cushing response
Herniation
A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered high. inaccurate. within normal limits. low.
low.
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? vasodilation vasoconstriction increased PaO hypertension
vasodilation
A client is receiving intravenous (IV) dobutamine (Dobutrex) to help provide adequate perfusion to the brain. The order is for dobutamine 50 mg in 500 mL D5W at 2 mcg/kg/min. The client weighs 58 kg. At how many mL per hour will the nurse administer this medication? Enter the correct number ONLY.
70
The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? 25 to 40 mm Hg 8 to 15 mm Hg 20 to 30 mm Hg 0 to 10 mm Hg
0 to 10 mm Hg
The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the priority nursing action? Provide ventriculostomy care. Inspect the ICP monitor to ensure it is working properly. Assess for signs and symptoms of infection. Administer acetaminophen per orders.
Administer acetaminophen per orders.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Bradycardia Tachycardia Pupillary constriction Hypertension Bradypnea
Bradycardia Bradypnea Hypertension
Which signs are manifestations of the Cushing triad? Select all that apply. Hypertension Bradypnea Bradycardia Tachycardia
Bradycardia Hypertension Bradypnea
The nurse caring for a client in a persistent vegetative state is regularly assessing for potential complications. The nurse should assess for which complications? Select all that apply. Pressure ulcers Pneumonia Venous thromboembolism Hemorrhage Contractures
Contractures Pressure ulcers Venous thromboembolism Pneumonia
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment? Flaccid Decorticate Decerebrate Rigid
Flaccid
The statements presented here match nursing interventions with nursing diagnoses. Which statements are appropriate for a client who has suffered a head injury? Select all that apply. Interrupted family process: Encourage the family to join a support group Deficient fluid volume: Administer 1 L of normal saline daily Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Ineffective cerebral tissue perfusion: Maintain cerebral perfusion pressure ≤50 mm Hg
Ineffective airway clearance: Apply suction as indicated Disturbed sleep pattern: Provide back rubs to the client Interrupted family process: Encourage the family to join a support group
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Myelography Computed tomography (CT) scan Radiography Neurologic examination
Neurologic examination
When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first? Contact the physician to review the care plan. Continue the assessment because no actions are indicated at this time. Check the equipment. Document the reading because it reflects that the treatment has been effective.
Check the equipment.
A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? Continuous BP monitoring Vigilant monitoring of fluid balance Monitoring of the client's airway for patency Serial arterial blood gases (ABGs)
Vigilant monitoring of fluid balance
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Elevating the head of the bed to 90 degrees Administering prescribed antipyretics Frequent oral care Encouraging deep breathing and coughing every 2 hours Maintaining aseptic technique with an intraventricular catheter
Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings? Oliguria and decreased urine osmolality Excessive urine output and serum hypo-osmolarity Oliguria and serum hyperosmolarity Excessive urine output and decreased urine osmolality
Excessive urine output and decreased urine osmolality
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. Nasal congestion Diaphoresis Hypertension Tachycardia Fever
Hypertension Diaphoresis Nasal congestion
In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find? Select all that apply. Hypothermia Diaphoresis Hypotension Tachycardia Tachypnea Venous pooling
Hypotension Venous pooling Tachypnea Hypothermia
A client arrives at the ED via ambulance following a motorcycle accident. The paramedics state the client was found unconscious at the scene but briefly regained consciousness during transport to the hospital. Upon initial assessment, the client's GCS score is 7. The nurse anticipates which action? IV administration of propofol An order for a head computed tomography scan Immediate craniotomy Intubation and mechanical ventilation
Immediate craniotomy
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy? Increased ICP is 12 mm Hg. The pupils are dilated and fixed. Cerebral perfusion pressure (CPP) is 21 mm Hg. The mean arterial pressure (MAP) is equal to the intracranial pressure (ICP).
Increased ICP is 12 mm Hg.
Following a motorcycle accident, 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? Nausea Lethargy Periorbital edema Blood pressure 100/60 mm Hg
Lethargy
A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome? Demonstrates optimal cerebral tissue perfusion Displays no signs or symptoms of infection Maintains a patent airway Attains desired fluid balance
Maintains a patent airway
A 58-year-old construction worker fell from a 25-foot scaffolding and incurred a closed head injury as a result. As his intracranial pressure continues to increase, the potential of herniation also increases. If the brain herniates, which of the following are potential consequences? Choose all correct options. Impaired cellular activity Permanent neurologic dysfunction Death Seizures Insomnia
Death Permanent neurologic dysfunction Impaired cellular activity
The nurse is caring for a client who sustained a moderate head injury following a bicycle accident. The nurse's most recent assessment reveals that the client's respiratory effort has increased. What is the nurse's most appropriate response? Inform the care team and assess for further signs of possible increased ICP. Administer a bolus of normal saline as prescribed. Increase the client's bed height and reassess in 30 minutes. Administer bronchodilators as prescribed and monitor the client's LOC.
Inform the care team and assess for further signs of possible increased ICP.
A nurse is preparing to administer an antiseizure medication to a client. Which of the following is an appropriate antiseizure medication? Lamisil Labetalol Lamictal Lomotil
Lamictal
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following? Dawn phenomenon Hashimoto's disease Cushing's Monro-Kellie
Monro-Kellie
A client is postoperative day 1 following intracranial surgery. The nurse's assessment reveals that the client's LOC is slightly decreased compared with the day of surgery. What is the nurse's best response to this assessment finding? Understand that the surgery may have been unsuccessful. Recognize the need to refer the client to the palliative care team. Recognize that this may represent the peak of postsurgical cerebral edema. Alert the surgeon to the possibility of an intracranial hemorrhage.
Recognize that this may represent the peak of postsurgical cerebral edema.
Which of the following are the immediate complications of spinal cord injury? Spinal shock Respiratory arrest Tetraplegia Autonomic dysreflexia Paraplegia
Respiratory arrest Spinal shock
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? Fluid restriction Diet containing extra sodium Vasopressin therapy Hypertonic saline solution
Vasopressin therapy
A nurse working in the neurologic intensive care unit admits from the emergency department a patient with an inoperable brain tumor. Of the two choices of posturing exhibited in the above image, which one demonstrates a deeper and more severe dysfunction? A (decorticating) B (decerebrate) both demonstrate severe dysfunction neither is considered severe
B
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following is cause of a secondary injury associated with brain injury? Select all that apply. Cerebral edema Seizures Infection Hyperthermia Ischemia
Cerebral edema Ischemia Infection Seizures Hyperthermia
Which method is used to help reduce intracranial pressure? Keeping the head of bed flat Using a cervical collar Extreme hip flexion, with the hip supported by pillows Rotating the neck to the far right with neck support
Using a cervical collar
A client undergoes a craniotomy with supratentorial surgery to remove a brain tumor. On the first postoperative day, the nurse notes the absence of a bone flap at the operative site. How should the nurse position the client's head? Turned onto the operative side Elevated 30 degrees Elevated no more than 10 degrees Flat
Elevated 30 degrees
Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? Risk for infection Ineffective cerebral tissue perfusion Risk for injury Fluid volume deficit
Ineffective cerebral tissue perfusion
Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Warm skin Venous pooling in the extremities Bradycardia Tachycardia Profuse bilateral sweating
Venous pooling in the extremities Bradycardia Warm skin
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings? Excessive urine output and decreased urine osmolality Oliguria and serum hyperosmolarity Oliguria and serum hyponatremia Excessive urine output and serum hyponatremia
Oliguria and serum hyponatremia
