Quiz #3 Neuro Unit

Which instructions should the nurse give a client who has been given a skeletal muscle relaxant for herniated intervertebral disk?

Avoid driving or operating equipment

The nurse is caring for a client whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be prescribed to control this?

Baclofen

A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?

Basilar

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?

Burr holes

At which of the following spinal cord injury levels does the patient have full head and neck control?

C5

A halo sign is indicative of which of the following complication of brain injury?

Cerebrospinal fluid (CSF) leak

The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity". How can the nurse best address this risk?

Change the client's position frequently

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?

Halo sign

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:

Increased intracranial pressure (ICP)

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?

Ineffective breathing pattern

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:

Leakage of cerebrospinal fluid (CSF)

Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?

Mannitol

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 neurologic deterioration may occur

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?

Paresthesia

A client with a T4-level spinal cord injury reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place client in a sitting position

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

A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes highest priority in this client's care plan?

Risk for injury

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

Spinal shock

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

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

T6

The earliest sign of serious impairment of brain circulation related to increasing ICP

a change in consciousness

A mother brings her 6-year-old to the emergency department after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

a concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain

A client with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

absence of reflexes along with flaccid extremities

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

absence of reflexes along with flaccid extremities

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

an area of bruising over the mastoid bone

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

an intracerebral hematoma

The nurse is caring for a client who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply

apnea, coma, absence of brain stem reflexes

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

applying thigh-high elastic stockings

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

because hypoxia can create or worsen a neurologic deficit of the spinal cord

A nurse is caring for a critically ill client with autonomic dysreflexia. What client manisfestation would the nurse expect in this client?

bradycardia and hypertension

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?

check the client's indwelling urinary catheter for kinks to ensure patency

A client had a long successful hockey career but has been forced to retire due to symptoms of depression, memory loss, and difficulty with gait and balance. The neurologist believes the most likely cause of these symptoms is:

chronic traumatic encephalopathy

A client receives a diagnosis of concussion. While speaking with the client, the nurse learns that this is the client's third head injury. This information is of particular significance because it puts the client at risk for:

chronic traumatic encephalopathy

The nurse planning the care of a client with head injuries is addressing the client's nursing diagnosis of "sleep deprivation". What action should the nurse implement?

cluster overnight nursing activities to minimize disturbances

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

A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural heatoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to

decrease the potential for brain damage

A male patient is brought to the ED by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be OK". Now the patient is complaining of severe headache and states that he is "not feeling well" The care team suspects and epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepare for which priority intervention?

emergency crainotomy

The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?

ensure that the player is not moved

Splints have been prescribed for a client who is at risk of developing footdrop following a spinal cord injury. The nurse should remove and reapply the splints when?

every 2 hours

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

herniation occurs through the foramen magnum

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

ineffective airway clearance related to brain injury

A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?

ineffective breathing patterns related to weakness of the intercostal muscles

A client is admitted to the neurologic ICU with a spinal cord injury. In writing the client's care plan, the nurse specifies that contractures can best be prevented by what action?

initiating (ROM) exercises as soon as possible after the injury

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?

it allows for stabilization of the cervical spine along with early ambulation.

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale(GCS). This allows the nurse to gauge what aspect of the client's status?

level of consciousness

The most important nursing priority of treatment for a patient with an altered LOC is to:

maintain a clear airway to ensure adequate ventilation

An older adult patient has been brought to the emergency department after being found unconscious by a neighbor. What action should the ED nurse's highest priority in the care of this patient?

maintain the patency of the patient's airway

A client is brought to the ED by her family after falling off the roof. The care team suspects and epidural hematoma, prompting the nurse to prepare for which priority intervention?

making openings in the skull

A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension?

monitor the client's BP before and during position changes

Which nursing intervention can prevent a client form experiencing autonomic dysreflexia?

monitoring the patency of an indwelling urinary catheter

A client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurse's best intervention for preventing injrury?

pad the side rails of the client's bed

The nurse recognizes that a client with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?

perform passive ROM exercises as prescribed

The staff educator is precepting a nurse new to the critical care unit when a client with a T2 spinal cord injury is admitted. The client is soon exhibiting manisfestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action?

prepare for interventions to increase the client's BP

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

raccoon's eyes and Battle sign

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to simuli. Which of the following is the initial nursing intervention to treat this condition?

raise the head of the bead and place the patient in a sitting position

Which are characteristics of autonomic dysreflexia?

severe hypertension, tachycardia, blurred vision, dry skin

A nurse on the neurologic unit is providing care for a client who has spinal cord injury at the level of C4. When planning the client's care, what aspect of the client's neurologic and functional status should the nurse consider?

the client will require full assistance for all aspects of elimination

A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse

the client's medications include warfarin (Coumadin)

A client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client's current health status is most likely to have precipitated this event?

the client's urinary catheter became occluded

The nurse is providing health education to a client who has a C6 spinal cord injury. The client asks why autonomic dysreflexia is considered an emergency. What would be the nurse' best answer?

the sudden increase in BP can raise the ICP or rupture a cerebral blood vessel

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions?

to dehydrate the brain and reduce cerebral edema

A client who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?

urinary catheters often lead to urinary tract infections

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:

vomits

Which finding indicates increasing inracranial pressure (ICP) in the client who has sustained a head injury?

widened pulse pressure

Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?

widened pulse pressure