NRS 222: CNS Emergencies

What is going to be our first imaging assessment for patients with a head injury? (Carol's previous exams)

CT is always done first MRI takes too long

The nurse is working with a 39-year-old client who has suffered a head injury as a result of a fall from a scaffold. Which of the conditions listed most likely describes increased intracranial pressure as a result of increased tissue volume? A) Hematoma B) Cerebral edema C) Intracranial hemorrhage D) Decreased venous drainage

Cerebral edema Increased intracranial pressure can develop in a client who has experienced a head injury. The increased ICP may develop as a result of increased tissue volume or because of an increase in cerebral blood volume. Conditions caused by increased tissue volume that lead to increased ICP include cerebral edema or brain lesions.

In a patient brought in the ED for a possible spinal injury, which would we do first? (Carol's previous exams) A) Take their vitals B) Give them pain medications C) Check their peripheral pulses D) Ensure that the cervical collar is properly in place

D. Ensure the cervical collar is properly in place.

Intracranial Pressure should normally be within what range?

10-15mmHg

With a TBI patient (or someone that we are monitoring for IICP) what is our goal pressure for ICP?

<20mmHg

A client has sustained a head injury. Which of the following is part of the nursing plan? Select all that apply. - Monitor electrolytes - Regulate hydration according to the intake and output - Evaluate level of consciousness - Obtain an EKG - Implement seizure precautions

Evaluate level of consciousness When a client suffers a head injury, the nurse should evaluate level of consciousness, do strict intake and output measurements, regulating hydration accordingly and implement seizure precautions. Hypothermia may be utilized depending on the severity of the injury. Implement seizure precautions A client with a head injury should be placed on seizure precautions until the extent of the injury is known. Regulate hydration according to the intake and output The nurse will need to follow strict intake and output according to the orders placed by the provider.

The nurse is caring for a client with a fever, headache, and stiff neck. Which intervention is the priority for this client? A) Lumbar puncture B) Fluid resuscitation C) Neck massage D) Fever control

Lumbar puncture When a client presents with a headache, fever, and stiff neck, the nurse will be suspicious of meningitis. The way to test for this is cerebral spinal fluid via a lumbar puncture. Until meningitis is confirmed, the client will also be on droplet isolation precautions.

Which of the following is a common cause of increased intracranial pressure (ICP)? A) Cerebral hypoxia B) Space-occupying lesion C) Brain herniation D) Decreased cerebral perfusion

Space-occupying lesion A space-occupying lesion, such as a brain tumor, is a potential cause of increased intracranial pressure. Other causes of increased ICP include hemorrhage, encephalitis, seizure and stroke, to name a few.

A client who has suffered a severe brain injury is being prepared for invasive intracranial pressure monitoring. Which of the following is considered a contraindication to this type of monitor? Select all that apply. - Brain tumor - Craniotomy - Coagulopathy - Hydrocephalus - Elevated INR

X -Brain tumor This is a source of increased ICP, so this is not contraindications for invasive ICP monitoring. Coagulopathy Increased intracranial pressure can occur due to trauma, hemorrhage, edema, inflammation and tumors. Intracranial pressure monitoring involves assessment of the amount of pressure with the client's brain, and begins with a nursing assessment of the client. A CT of the head can be done to detect internal variances in brain, such as the midline shift, edema, lesions and abnormal brain structure. Invasive ICP monitoring is initiated by placement of an intraventricular catheter into a brain ventricle. This type of monitor should not be used if the client has bleeding tendencies. X -Craniotomy This is a term used to describe surgery in which a part of the skull is removed to access the inside of the brain. Increased ICP can be a indication to perform a craniotomy, therefore craniotomy is not a contraindication to invasive ICP monitoring. Elevated INR If the client has an international normalized ration (INR) of >1.3, this means their blood takes longer to clot, so ICP monitoring is contraindicated. X -Hydrocephalus This is also a source of increased ICP, so this is not contraindications for invasive ICP monitoring.

A client who has had a lumbar puncture develops a severe headache after attempting to sit up in bed. The nurse recognizes this complication as which of the following? A) An exertional headache B) A post-dural headache C) A cluster headache D) An ictal headache

A post-dural headache A client who undergoes a lumbar puncture has the potential for complications. One of the most common complications is a post-dural puncture headache, also called a spinal headache. This occurs when some of the cerebrospinal fluid leaks through the dura mater when it is punctured. It can be treated with a blood patch that involves injecting blood into the space to form a clot.

An early sign of increased intracranial pressure includes which of the following? A) Elevated ammonia level B) Decreased respiratory rate C) Tachycardia D) Altered level of consciousness

Altered level of consciousness An early sign of increased intracranial pressure include an altered level of consciousness, blurry vision, and a headache

A 22-year-old client has suffered a spinal cord injury in which he is experiencing spinal shock and cannot feel his legs. Twenty-four hours after the injury, the client tells the nurse, "This will be good for me. I can handle this and I'm doing fine." Which response from the nurse is most likely indicated? A) Ask the client if he would like to speak with a spiritual advisor or social worker B) Document the client's positive attitude regarding this life-changing disability C) Continue to treat the client as is but remind him that he may never walk again D) Make arrangements for the client to be discharged to home

Ask the client if he would like to speak with a spiritual advisor or social worker The client in the situation described may most likely be suffering from denial as an initial response after the injury. Not all people who are injured and who develop paraplegia will react the same way, but many people who are injured in this method develop anxiety and depression and may have difficulties coping with the outcome of the situation. Some clients develop denial initially after the injury, which often resolves after several months. In this case, the nurse may want to offer a resource such as a social worker or spiritual advisor.

A nurse is assisting the provider with a lumbar puncture on a client with potential meningitis. Which actions are part of assisting with a lumbar puncture? Select all that apply. - Monitor the puncture site for bleeding or leakage of CSF fluid - Insert the needle into the lower portion of the spine - Calibrate the cerebrospinal fluid pressure - Assist the client with lying still during the procedure - Assist the client to lie in the lateral recumbent position

Assist the client to lie in the lateral recumbent position A nurse who assists with a lumbar puncture is typically responsible for keeping the client comfortable. The nurse should assist with positioning the client into the lateral recumbent position, with the knees drawn up to the abdomen and the chin onto the chest. While the nurse might monitor for complications, she does not perform any aspects of the procedure. Assist the client with lying still during the procedure A nurse who assists with a lumbar puncture is typically responsible for keeping the client comfortable. The nurse should assist with positioning the client into the lateral recumbent position, with the knees drawn up to the abdomen and the chin onto the chest. While the nurse might monitor for complications, she does not perform any aspects of the procedure. Monitor the puncture site for bleeding or leakage of CSF fluid A nurse who assists with a lumbar puncture is typically responsible for keeping the client comfortable. The nurse should assist with positioning the client into the lateral recumbent position, with the knees drawn up to the abdomen and the chin onto the chest. While the nurse might monitor for complications, she does not perform any aspects of the procedure.

In a pediatric patient with IICP concerns or a recent TBI, which of the following would we correct? (Carol's previous exams) A) The CNA taking an axillary temperature B) The CNA flexing the baby's hips during a bed bath C) The CNA holding the baby D) The CNA wiping the baby with wipes from home.

B. Flexing the baby's hips can increase the ICP.

The nurse receives report on a client on blood thinners who fell down the stairs and has periorbital ecchymosis. The head CT came back with an intracerebral hemorrhage. Which of the following is the most important to monitor closely? A) Heart rate B) Blood pressure C) Pain D) Temperature

Blood pressure A client with an intracerebral hemorrhage will require a blood pressure within a very narrow range. Increased pressure in the vessels increases bleeding and intracranial pressure. When the blood pressure becomes too low, there is a risk for vasospasms.

The client has a spinal cord injury and is suffering from spinal shock. Which of the following is an expected symptom in spinal shock? A) Hypertension B) Increased visceral reflexes C) Bradycardia D) Spasticity

Bradycardia A client with spinal shock is expected to be hypotensive, have bradycardia, decreased visceral reflexes and flaccid paralysis of skeletal muscles.

A 31-year-old client has developed meningococcal meningitis after recently traveling out of the United States. Which type of precautions would the nurse most likely implement in this situation? A) Airborne precautions B) Droplet precautions C) Custom precautions D) Contact precautions

Droplet precautions Bacterial meningitis is a bacterial infection of the membrane covering the brain and spinal cord. The condition can be transmitted between clients and certain types of meningitis require droplet precautions. Therefore, the nurse will utilize droplet precautions until the type of bacteria is known.

A nurse is caring for a client who suffered from a bilateral subdural hematomas whose ICP has been ranging from 15-20 mm Hg. Which of the following orders should the nurse question? A) Lumbar puncture B) Foley catheter insertion C) Central venous catheter insertion D) Mechanical intubation

Lumbar puncture Lumbar punctures are contraindicated in clients with increased ICP, as the cerebrospinal fluid will rush out of the puncture site, the brain can become compressed towards the foramen magnum and subsequent (and occasionally immediate) damage (herniation) can result. The nurse should absolutely question this order.

A client who has experienced a head injury is being cared for by the nurse in the ICU. The client has a monitor in place to check intracranial pressure and the nurse notes that the pressure is increasing. Which of the following interventions by the nurse should be done to control increasing intracranial pressure? A) Instruct the client to perform the Valsalva maneuver B) Reposition the intracranial monitor C) Maintain oxygen delivery to prevent hypoxia D) Elevate the head of the bed to 90 degrees

Maintain oxygen delivery to prevent hypoxia Intracranial pressure refers to the pressure exerted by cerebrospinal fluid inside the skull. Intracranial pressure may increase if a client has a head injury, causing changes in the level of consciousness and decreased blood flow to the brain. If a client is experiencing increased intracranial pressure, the nurse should take measures to reduce it or prevent it from worsening. In this case, the nurse should increase oxygen to the client, because increased ICP leads to hypoxia which can further contribute to increased intracranial pressure as the body responds by increasing blood flow to the brain

The nursing care plan of a client with spinal cord injury should include which of the following? Select all that apply. - Administer antispasmodics - Provide skeletal traction - Prepare client for surgical stabilization of spine - Maintain stable vital signs - Begin aggressive steroid therapy

Maintain stable vital signs A client with a spinal cord injury will have multiple issues that need managed by the nurse. The client experiences loss of sensory function below the level of the injury, and is at risk for hypotension, bradycardia, and other symptoms of autonomic dysreflexia and neurogenic shock. In caring for a client with spinal cord injury, the nurse should maintain stable vital signs, provide skeletal traction, give steroid therapy, prepare the client for surgical stabilization, and administer antispasmodics. Provide skeletal traction Skeletal traction is appropriate for the client with a spinal cord injury. Prepare client for surgical stabilization of spine The client may need surgical stabilization, and the nurse would need to prepare the client for surgery. Administer antispasmodics Antispasmodics administered as ordered are part of the nursing care for a client with a spinal cord injury.

Which of the following factors increase the risk of spinal cord injury? Select all that apply. - African American or Asian ethnicity - Male gender - Underlying kidney disease - Underlying arthritis - Age between 16 and 30

Male gender Spinal cord injury occurs with damage to an area of the spinal cord and outlying nerves. Significant injury often causes loss of sensation and function in the body below the area of injury. Spinal cord injury can occur from a traumatic event or through a disease process that affects the bones and joints. Men and teen boys between the ages of 16 and 30 years are at higher risk of incurring a traumatic spinal cord injury. The presence of certain bone or joint diseases, such as osteoporosis or arthritis can also increase the risk of this type of injury. Age between 16 and 30 Spinal cord injury occurs with damage to an area of the spinal cord and outlying nerves. Significant injury often causes loss of sensation and function in the body below the area of injury. Spinal cord injury can occur from a traumatic event or through a disease process that affects the bones and joints. Men and teen boys between the ages of 16 and 30 years are at higher risk of incurring a traumatic spinal cord injury. The presence of certain bone or joint diseases, such as osteoporosis or arthritis can also increase the risk of this type of injury. Underlying arthritis Spinal cord injury occurs with damage to an area of the spinal cord and outlying nerves. Significant injury often causes loss of sensation and function in the body below the area of injury. Spinal cord injury can occur from a traumatic event or through a disease process that affects the bones and joints. Men and teen boys between the ages of 16 and 30 years are at higher risk of incurring a traumatic spinal cord injury. The presence of certain bone or joint diseases, such as osteoporosis or arthritis can also increase the risk of this type of injury.

A client is in the emergency room for a traumatic brain injury, caused by a fall. The nurse sees an order for mannitol and knows that this medication is used as primarily for as which of the following? A) Loop diuretic B) Hyperglycemic C) Antihypertensive D) Osmotic diuretic

Osmotic diuretic Mannitol is an osmotic diuretic used for increased intracranial pressure to reduce the ICP by reducing cerebral cell water.

A client is preparing to undergo spinal surgery. In which position should the nurse place the client to best prevent injury during the surgical procedure? A) Lithotomy B) Trendelenburg C) Prone D) Sims' position

Prone "Prone" is correct. The nurse in the operating room must be familiar with the appropriate position for the client based on the procedure performed. Proper positioning is also important to keep the client safe during the procedure. A spinal procedure involves operating on the client's back, so the nurse should position the client prone with head turned to the side, with special padding provided for the face and neck.

The nurse is caring for a client with bacterial meningitis. Which of the following is a priority nursing intervention? A) Provide IV antibiotics B) Place client on airborne precautions C) Give the Hib vaccine D) Provide analgesia

Provide IV antibiotics The priority nursing intervention is to give IV antibiotics. After this, it's important to place the client on droplet precautions, then manage symptoms.

A nurse is caring for a client with a spinal cord injury sustained 5 years ago. The clients' level of injury is outlined in the image (paralyzed from waist down). Which of the following findings in this client would the nurse NOT expect to see? A) Shallow respirations B) Lack of bowel and bladder control C) Patient reports feeling cold D) Lack of sensation to the right foot

Shallow respirations The patient does not have any involvement of his abdominal or chest wall muscles, or the diaphragm. With a higher level injury, we may expect to see shallow respirations. However, this client should not experience this. If this finding exists, it is a cause for concern.

A client with a spinal cord injury has difficulty determining when the bladder needs emptied. The nurse teaches the client about tapping to stimulate voiding. How would the nurse describe tapping to this client? A) The area over the bladder is tapped to stimulate the bladder muscles B) The client wears a device that acts as a tap or faucet to stop and start urine flow C) The client alternately taps the abdomen and the back to signal messages across the body to promote urination D) The client bears down to increase pressure and then taps the base of the abdomen to release urine

The area over the bladder is tapped to stimulate the bladder muscles A client with a spinal cord injury may be unable to control urine flow if there is little to no sensation in the bladder that tells the brain when it is time to empty the bladder. The nurse can teach the client techniques to stimulate urine flow. Tapping involves lightly tapping the area over the bladder with the fingertips to stimulate detrusor muscle contractions.

A nurse is caring for a child with meningitis and wants to wear two pairs of gloves while working with him. Which of the following statements regarding double gloves is true? A) Double gloving is outside the scope of practice for a nurse because it is unnecessary B) The glove failure rate is higher in single gloves than in double gloves C) Double gloving should only be done with certain procedures on highly infectious clients D) The nurse will have significantly decreased sensitivity if two pairs of gloves are used

The glove failure rate is higher in single gloves than in double gloves Double gloving describes the process of wearing two pairs of disposable gloves when caring for a client, such as during a medical procedure or during surgery. Because tears can occur in disposable gloves, it has been shown that the likelihood of transmission of an infection is reduced when the nurse wears two pairs of gloves. Double gloving has not been shown to significantly reduce tactile sensitivity and it may be done in any situation that the nurse feels is necessary, not just for specific types of client illnesses.

A nurse is setting up a sterile field to assist with a lumbar puncture on a client suspected of having meningitis. Which practices should the nurse perform during the client's procedure that would uphold the sterile technique? Select all that apply. - The nurse sterilizes the client's skin with isopropyl alcohol before starting - The nurse should get a new package is there is evidence of dried water marks on the package - The nurse opens the package by folding the flap opening toward him or herself first - The nurse uses the contents of the sterile package right away and does not leave them sitting out - The nurse confirms that the package of sterile instruments is intact before opening it

The nurse confirms that the package of sterile instruments is intact before opening it The sterile field is set up as an area where sterile instruments that will be used on the client are not touched or used except by other sterile instruments or sterile gloved hands. The nurse upholds the sterile field by opening packages toward the sterile field (and away from self), inspecting them before use to be sure they have not been contaminated, and using them right away to minimize the risk of contamination. The nurse should get a new package is there is evidence of dried water marks on the package The sterile field is set up as an area where sterile instruments that will be used on the client are not touched or used except by other sterile instruments or sterile gloved hands. The nurse upholds the sterile field by opening packages toward the sterile field (and away from self), inspecting them before use to be sure they have not been contaminated, and using them right away to minimize the risk of contamination. The nurse uses the contents of the sterile package right away and does not leave them sitting out The sterile field is set up as an area where sterile instruments that will be used on the client are not touched or used except by other sterile instruments or sterile gloved hands. The nurse upholds the sterile field by opening packages toward the sterile field (and away from self), inspecting them before use to be sure they have not been contaminated, and using them right away to minimize the risk of contamination.

A client is being seen in the emergency department after a spinal cord injury. The client initially states an inability to feel anything below the shoulders. At which point would this client need to be intubated with an endotracheal tube? A) The point at which the client has a Glasgow Coma Score of 8 B) Upon discovering that the client has a pneumothorax as seen on x-ray C) The point at which the client's oxygen saturation is 88 percent on room air D) The point at which the client has a respiratory rate of 10/minute

The point at which the client has a Glasgow Coma Score of 8 A spinal cord injury produces paresthesia below the level of the injury; paraplegia indicates an injury in which the patient cannot move the lower extremities, while quadriplegia is a higher-level injury where the patient often cannot move the upper or lower extremities. With a higher-level injury, the patient may also need breathing support; if the spinal cord was injured above the level that stimulates breathing, the patient may need intubation. Respiratory failure is an indication for intubation, as is a GCS result of <9, which indicates a decreased level of consciousness.

A nurse has gathered an interdisciplinary team to work together to coordinate care for a client with a spinal cord injury. Which best describes the nurse's role in collaborating with other members of the team to provide care for this client? A) Documenting in the client's chart that the team meeting will take place B) Being a source of professional guidance when a team member needs information about therapy C) Updating the team members about the status of the client's health D) Informing the client that the team will have a meeting

Updating the team members about the status of the client's health The members of the interdisciplinary team may often gather to discuss a client's condition and to make plans for care. The nurse often acts as a team coordinator by ensuring that appropriate disciplines are present and by updating the members of the team about the client's status. Because the nurse is the most likely person who will provide direct care to the client on a regular basis, the nurse is the one who can update the team about the client's progress.

The most appropriate prevention against spinal cord injury is which of the following actions? A) Drink in moderation before driving B) Use seat belts in the car C) Avoid horseback riding without a helmet D) Avoid surfing

Use seat belts in the car The most appropriate prevention against spinal cord injury is to use seat belts in the car, as motor vehicle accidents are the leading cause of spinal cord injuries, accounting for 39%.