PrepU ch68 Management of pts w/neuro trauma

The earliest sign of serious impairment of brain circulation related to increased ICP is: A bounding pulse. Bradycardia. Hypertension. A change in consciousness.

A change in consciousness

Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? Apply elastic stockings to lower extremities. Take care not to jar the bed or cause unnecessary activity. Assist the patient with frequent ambulation. Elevate patient's head or follow the physician's directive for body position.

Apply elastic stockings to lower extremities.

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region? Numbness and tingling Respiratory pattern Pulse and blood pressure Pain level

Pulse and blood pressure

What type of skull fractures may be evident by Battle's sign?

basilar A clinical manifestation of a basilar skull fracture is the Battle's sign (an area of ecchymosis may be seen over the mastoid).

At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. Bradypnea Bradycardia Hypotension Hypertension Tachycardia

bradycardia HTN bradypnea The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

shifting of brain tissue from an area of high pressure to an area of low pressure?

herniation

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? Decreased heart rate Bradycardia Alteration in level of consciousness (LOC) Slurred speech

Alteration in level of consciousness (LOC)

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. Hypotension Tachycardia Venous pooling Diaphoresis Tachypnea Hypothermia

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? Immediate craniotomy An order for a head computed tomography scan Intubation and mechanical ventilation IV administration of propofol

Immediate craniotomy

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? S2 L4 T6 T10

T6 Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

Clinical manifestations of neurogenic shock include which of the following? Select all that apply. Venous pooling in the extremities Bradycardia Warm skin Tachycardia Profuse bilateral sweating

Venous pooling in the extremities Bradycardia Warm skin

Which are possible long-term complications of spinal cord injury? Select all that apply. respiratory arrest areflexia autonomic dysreflexia respiratory infection

autonomic dysreflexia respiratory infection

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: decrease the potential for brain damage. assess for infection. follow hospital protocol. prevent embolism.

decrease the potential for brain damage.

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

intracerebral hematoma

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? C3 C5 T6 L1

C5 The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.

Which are risk factors for spinal cord injury (SCI)? Select all that apply. European American ethnicity Alcohol use Young age Drug abuse Female gender

young age ETOH use drug abuse

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

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? To increase cerebral perfusion pressure Because hypoxemia can create or worsen a neurologic deficit of the spinal cord To prevent secondary brain injury So that the patient will not have a respiratory arrest

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

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

Spinal Shock Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

The nurse received the report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has cerebral spinal fluid (CSF) leaking from the ear. The client has ecchymosis in the periorbital region. The client has an elevated temperature. The client has serous drainage from the nose.

The client has cerebral spinal fluid (CSF) leaking from the ear.

A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain? allodynia hyperalgesia nociceptive idiopathic

allodynia Allodynia is a type of neurogenic pain whereby clients experience pain in response to a normally painless stimulus. Hyperalgesia is a type of neurogenic pain whereby clients experience an increased response to a painful stimulus. Nociceptive pain is detected by specialized sensory nerves located throughout the soft tissues and is not neurogenic. Idiopathic pain has no apparent underlying cause and is not neurogenic.

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? Tetraplegia Areflexia Autonomic dysreflexia Paraplegia

autonomic dysreflexia

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

decerebrate

A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report?

parasthesia

A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as:

severe TBI 13 to 15 - mild TBI 9 to 12 - mod 3 to 8 - severe score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; score of 8 or less typically indicates an unconscious patient; score of 15 indicates a fully alert and oriented patient.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction? "I will change the vest liner periodically." "If a pin becomes detached, I'll notify the surgeon." "I can apply powder under the liner to help with sweating." "I'll check under the liner for blisters and redness."

"I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect? Autonomic dysreflexia Thrombophlebitis Orthostatic hypotension Spinal shock

Autonomic dysreflexia Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.

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? Hypophysectomy Application of Halo traction Burr holes Insertion of Crutchfield tongs

Burr holes

A nurse is caring for a client with L1-L2 paraplegia who is undergoing rehabilitation. Which goal is appropriate? Establishing an intermittent catheterization routine every 4 hours Managing spasticity with range-of-motion exercises and medications Establishing an ambulation program using short leg braces Preventing autonomic dysreflexia by preventing bowel impaction

Establishing an intermittent catheterization routine every 4 hours

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 Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed A head elevation of 90 degrees to prevent cerebral swelling

Flat, except for logrolling as needed when caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.

The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? It refers to the difficulties suffered by the client and family related to the changes in the client. It results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process. It results from inadequate delivery of nutrients and oxygen to the cells.

It results from inadequate delivery of nutrients and oxygen to the cells. Secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually as a result of cerebral edema and increased intracranial pressure. Primary injury results from initial damage related to the traumatic event.

The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse? Tylenol may be administered for aches. Observe for any signs of behavioral changes. A light meal may be eaten if desired. Follow up with regular physician is encouraged.

Observe for any signs of behavioral changes All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.

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? Provide factual information and emotional support. Allow family members distance and space to deal with the changes to the client. Wait for the family members to approach with questions. Reassure them that progress will be made, but it takes time.

Provide factual information and emotional support.

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. Which of the following is the initial nursing intervention to treat this condition? Examine the skin for any area of pressure or irritation. Examine the rectum for a fecal mass. Empty the bladder immediately. Raise the head of the bed and place the patient in a sitting position.

Raise the head of the bed and place the patient in a sitting position.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air Temperature increase from 98.0°F to 99.6°F Urinary output increase from 40 to 55 mL/hr

Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? The client with an open head injury The client with a basilar fracture The client with a concussion The client with a coup injury

The client with a basilar fracture

Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? Contusion Intracerebral Subdural Epidural

epidural Symptoms of the epidural hematoma are caused by the expanding hematoma. Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval). Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid.

A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing:

raccoons eyes and battle sign A basilar skull fracture commonly causes only periorbital ecchymosis (raccoon's eyes) and postmastoid ecchymosis (Battle sign); however, it sometimes also causes otorrhea, rhinorrhea, and loss of cranial nerve I (olfactory nerve) function. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.

A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.

0.5 (50 mg/80 mg) X 0.8 mL = 0.5 mL.

The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Concussion Autonomic dysreflexia Spinal shock Contusion

Autonomic dysreflexia

A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Irrigates the wound to remove debris Administers an oral analgesic for pain Administers acetaminophen (Tylenol) for headache Shaves the hair around the wound

Irrigates the wound to remove debris

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

absence of reflexes along with flaccid extremities

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?

allows for stabilization of the cervical spine alonf with early ambulation

The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?

80 20/15 × 60 = 80 mL/hr

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? acute chronic subacute intracerebral

Acute

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension? Apply anti-embolic stockings prior to elevation of the head. Avoid binders around the abdominal area. Practice with the client raising the head in one smooth, quick motion. Avoid vasopressor medication for 2 hours prior to the client sitting up

Apply anti-embolic stockings prior to elevation of the head.

A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5

C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply. Cerebral edema Ischemia Infection Seizures Hyperthermia

Cerebral edema Ischemia Infection Seizures Hyperthermia

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? Change in level of consciousness (LOC) Seizures Restlessness Pupil changes

Change in LOC

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? Extradural hematoma Epidural hematoma Subdural hematoma Intracranial hematoma

Epidural hematoma An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.

A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Lower back pain Burning sensation on urination Frequency of urination Fever and change in urine clarity

Fever and change in urine clarity Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: Coma Absence of brain stem reflexes Apnea Glasgow Coma Scale of 6

Glasgow Coma Scale of 6

Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Hemiparesis Tachypnea Decreased reactivity of the pupils Bradycardia Hypotension Coma

Hemiparesis Decreased reactivity of the pupils Bradycardia Coma

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. Hypertension Tachycardia Fever Diaphoresis Nasal congestion

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. Hypotension Tachycardia Venous pooling Diaphoresis Tachypnea Hypothermia

Hypotension Venous pooling Tachypnea Hypothermia

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? Insertion of a nasogastric tube A large volume enema Digital stimulation Bowel surgery

Insertion of a nasogastric tube Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration.

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Placing the client in Trendelenburg's position Monitoring the patency of an indwelling urinary catheter

Monitoring the patency of an indwelling urinary catheter

The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is Falls Sports-related injuries Motor vehicle crashes Acts of violence

Motor vehicle crashes The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%). Males account for 80% of clients with SCI. An estimated 50% to 70% of SCIs occur in those aged 15 to 35 years.

A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? Place the patient in a sitting position. Call the physician. Assess the patient for a full bladder. Assess the patient for a fecal impaction.

Place the patient in a sitting position.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? Diarrhea Placing the client in a sitting position Placing a blanket over the client Voiding

Placing a blanket over the client

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? Disturbed sensory perception (visual) Dressing or grooming self-care deficit Impaired verbal communication Risk for injury

Risk for injury

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

Spasticity

Neurological level of spinal cord injury refers to which of the following? The lowest level at which sensory and motor function is normal The level of the spinal cord transection The highest level at which sensory and motor function is normal The best possible level of recovery

The lowest level at which sensory and motor function is normal

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Voice or sip-n-puff controlled electric wheelchair Electric or modified manual wheelchair, needs transfer assistance Cane The patient will be able to ambulate independently.

The patient will be able to ambulate independently.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? Cervical collar Cast Traction with weights and pulleys Turning frame

Traction with weights and pulleys Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as coma. minimally responsive. least responsive. most responsive.

coma

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Insertion of a nasogastric (NG) tube Serum sodium concentration testing Urine testing for acetone Out of bed to the chair three times a day

insertion of NG tube

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP?

keep the clients neck in a neutral position (no flexing)

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

look for signs of IICP

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness? Concussion Contusion Diffuse axonal injury Intracranial hemorrhage

Contusion Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

There is a high risk for ineffective coping in a client with a recent spinal cord injury. Which nursing interventions will assist the client with this process? Select all that apply. Assist the client in accepting the severity of deficits. Offer encouragement as the client makes progress. Involve the client actively in self care. Reassure the client by stating, "Everything is going to be all right."

Offer encouragement as the client makes progress. Involve the client actively in self care.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? Rebound hypotension Rebound hypertension Urinary tract infection Spinal shock

Rebound hypotension When the cause is removed and the symptoms abate, the blood pressure goes down. The antihypertensive medication is still working. The nurse must watch for rebound hypotension. Rebound hypertension is not an issue. Spinal shock occurs right after the initial injury. The client is not at any more risk for a urinary tract infection after the episode than he was before.

Which of the following are the immediate complications of spinal cord injury? Respiratory arrest Tetraplegia Spinal shock Paraplegia Autonomic dysreflexia

Respiratory arrest Spinal shock

Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. Motor Response Verbal response Muscle strength eye opening intelligence

eye opening verbal response motor response

While riding a bicycle in a race, a patient fell into a ditch and sustained a head injury. Another cyclist found the patient lying unconscious in the ditch and called 911. What type of concussion does the patient most likely have? Grade 1 concussion Grade 2 concussion Grade 3 concussion Grade 4 concussion

grade 3 concussion there are only 3 grades grade 1 - confusion, no loss of consciousness, mental abnormalities less than 15 min grade 2 - confusion, no loss of consciousness, mental abnormalities more than 15 min grade 3 - loss of consciousness

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?

monitoring is needed as rapid neuro deterioration may occur

Which are characteristics of autonomic dysreflexia? severe hypertension, slow heart rate, pounding headache, sweating severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, slow heart rate, anxiety, dry skin severe hypotension, tachycardia, nausea, flushed skin

severe hypertension, slow heart rate, pounding headache, sweating Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

subdural

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

subdural hematoma

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? Concussion Contusion Diffuse axonal injury Intracranial hemorrhage

Contusion Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern? Temperature increase from 98.0°F to 99.6°F Urinary output increase from 40 to 55 mL/hr Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air

Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

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 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.

The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation Ensuring that the patient regains full brain function

Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. nutritional protocol will be effective after the client sedation therapy is tapered. to continue IV administration of other scheduled medications. payment status will change if the client isn't sedated.

she will have to apply restraints to keep client fro dislodging ET

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders? The second cervical vertebrae The first thoracic vertebrae The seventh thoracic vertebrae The first lumbar vertebrae

the first thoracic vertebrae

A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? Lung auscultation and measurement of vital capacity and tidal volume Evaluation for signs and symptoms of increased intracranial pressure (ICP) Evaluation of pain and discomfort Evaluation of nutritional status and metabolic state

Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Radiography Myelography Neurologic examination Computed tomography (CT) scan

Neurologic examination A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client reports HA reports generalized weakness sleeps for short periods of time vomits

vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased pulse Increased respirations Widened pulse pressure Decreased body temperature

Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.

The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? A. Administer opioids to the client B. Apply an external urinary sheath catheter C. Provide a dimly lit room D. Turn and reposition the client every 2 hours

apply an external urinary sheath catheter

While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? 6 to 8 hours 18 to 36 hours 12 to 24 hours 48 to 72 hours

18 to 36 hours Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.

A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? Lorazepam (Ativan) Midazolam (Versed) Phenobarbital Propofol (Diprivan)

Propofol (Diprivan) If the patient is very agitated, benzodiazepines are the most commonly used sedative agents and do not affect cerebral blood flow or ICP. Lorazepam (Ativan) and midazolam (Versed) are frequently used but have active metabolites that my cause prolonged sedation, making it difficult to conduct a neurologic assessment. Propofol ( Diprivan), on the other hand, a sedative-hypnotic agent that is supplied in an intralipid emulsion for intravenous (IV) use, is the sedative of choice. It is an ultra-short acting, rapid onset drug with elimination half-life of less than an hour. It has a major advantage of being titratable to its desired clinical effect but still provides the opportunity for an accurate neurologic assessment

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client has periorbital edema and ecchymosis. The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The client's level of consciousness has improved. The client prefers to rest in the semi-Fowler's position.

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? Signs of infection Intake and output Nutritional status Body temperature

body temperature It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

suction the airway

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? Take daily weights. Reposition the client frequently. Assess for pupillary response frequently. Assess vital signs frequently.

take daily weights

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

Eating Breathing Transferring to a wheelchair Writing

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. Ecchymosis over thee mastoid B. Bruising under the eyes C. drainage of cerebrospinal fluid from the nose D. Drainage of cerebrospinal fluid from the ears

ecchymosis over the mastoid

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency room. The medic reports that a client is unconscious with edema of the head and face and Battle's sign. What clinical picture would the nurse anticipate? A. Edema to the head with a large scalp laceration B. Edema to the head with bruising of the mastoid process C. Edema to the head with fixed pupils D. Edema to the head and a blackened eye

edema to the head with bruising of the mastoid process

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: naloxone (Narcan). famotidine (Pepcid). nitroglycerin (Nitro-Bid). atracurium (Tracrium).

famotidine (Pepcid). Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?

risk for injury related to neuro deficit

The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation? A. Escape of cerebrospinal fluid from the client's ear B. A bloodstain surrounded by a yellowish stain on the head dressing C. Escape of cerebrospinal fluid from the client's nose D. An area of bruising over the mastoid bone

an area of bruising over the mastoid bone 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 sign). Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea). Drainage of CSF is a serious problem because meningeal infection can occur if organisms gain access to the cranial contents via the nose, ear, or sinus through a tear in the dura. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a CSF leak.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Reassure the client that a headache is expected and will go away without treatment. Notify the physician; a headache is an early sign of worsening neurologic status.

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. Headache is common after a head injury. Therefore, the nurse should administer acetaminophen to try to manage the client's pain without causing sedation. The nurse should then reassess the client in 30 minutes to note the effectiveness of the pain medication. Administering codeine, an opioid, could cause sedation that may mask changes in the client's neurologic status. Although a headache is expected, the client should receive treatment to alleviate pain. The nurse should notify the physician if the client's neurologic status changes or if treatment doesn't relieve the headache.

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 laceration contusion skull fracture

Concussion

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Ineffective cerebral tissue perfusion related to increased intracranial pressure Disturbed thought processes related to brain injury Ineffective airway clearance related to brain injury

Ineffective airway clearance related to brain injury Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? A. Position the client in the supine position B. Maintain cerebral perfusion pressure from 50 to 70 mm Hg C. Restrain the client, as indicated D. Administer enemas, as needed

Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? Continuous use of an indwelling catheter Meticulous cleanliness Avoidance of all lotions and lubricants Allowing the client to choose the position of comfort

Meticulous cleanliness Meticulous cleanliness is the best choice for preventing pressure ulcers. A continuous indwelling catheter is not conducive to preventing pressure ulcers. Pressure-sensitive areas should be kept well lubricated with lotion. The client does not know the best positioning techniques for prevention of skin breakdown. The nurse and client together should decide how to best position the body.