PREP U Chapter 45 Pellico

Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical. 80 mg/dL 120 mg/dL 140 mg/dL 180 mg/dL

180 mg/dL Explanation: A serum glucose level of over 150 mg/dL is considered a critical value.

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

Basilar skull fracture Explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? A brain lesion that causes a spontaneous response that changes with electrical activity in the brain Cerebral hemisphere pathology that will cause alterations in flaccidity and contraction of motor responses Decorticate positioning indicating damage to the upper midbrain Decerebrate positioning implying severe dysfunction and brain pathology

Decerebrate positioning implying severe dysfunction and brain pathology Explanation: Decorticate posture (extension and external rotation) is indicative of brain pathology. Decerebrate posturing indicates deeper and more severe dysfunction than decorticate posturing.

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation? Epidural hematoma Acute subdural hematoma Chronic subdural hematoma Grade 1 concussion

Epidural hematoma Explanation: Epidural hematomas are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. The patient then becomes increasingly restless, agitated, and confused as the condition progresses to coma.

What are the immediate complications of spinal cord injury? Select all that apply. respiratory arrest spinal shock tetraplegia paraplegia

respiratory arrest spinal shock Explanation: Spinal shock can be an immediate complication of spinal cord injury.

Which of the following conditions occurs when there is bleeding between the dura mater and arachnoid membrane? Intracerebral hemorrhage Epidural hematoma Extradural hematoma Subdural hematoma

Subdural hematoma Explanation: A subdural hematoma is bleeding between the dura mater and arachnoid membrane. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

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? Tetraplegia Areflexia Autonomic dysreflexia Paraplegia

Autonomic dysreflexia Explanation: 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 subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

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? Impaired physical mobility Ineffective breathing pattern Disturbed sensory perception (tactile) Dressing or grooming self-care deficit

Ineffective breathing pattern Explanation: Because a cervical spine injury can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.