TTC NUR205: MedSurgII Chapter 45 PrepU (Neurological Trauma)
A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make?
"They help prevent the development of contractures."
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
Hyperglycemia for a patient with a TBI may worsen the outcome of recovery. Select a serum glucose level that is considered critical.
180 mg/dL
The nurse is caring for a client in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is the normal range of intracranial pressure (ICP) for the client?
5 to 15 mm Hg
Which Glasgow Coma Scale score is indicative of a severe head injury?
7
Paramedics have brought an intubated patient to the emergency department following a head injury due to acceleration-deceleration motor vehicle accident. Increased intracranial pressure (ICP) is suspected. An appropriate nursing intervention would include what?
Administer antipyretics on a p.r.n. basis
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern?
Airway clearance
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
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?
Apply an external urinary sheath catheter
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.
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?
Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.
A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments?
Assessing the patient's blood pressure
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
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except?
Being an athlete
A client with a spinal cord injury has full head and neck control when the injury is at which level?
C5
A middle-aged male has been brought to the emergency department by ambulance after being found unconscious by police with injuries consistent with an assault. Injuries on the man's face and skull necessitate prompt assessment for traumatic brain injury. What neuroimaging tests are best able to yield clinically meaningful data? Select all that apply.
Computed tomography (CT) Magnetic resonance imaging (MRI)
Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?
Contusion
A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
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 which of the following?
Decerebrate
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?
Decerebrate positioning implying severe dysfunction and brain pathology
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?
Decorticate
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)?
Epidural
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
Epidural
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?
Epidural hematoma
A client is demonstrating an altered level of consciousness from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function?
Glasgow Coma Scale
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:
Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea.
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 3 concussion
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?
Herniation
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 Diaphoresis Nasal congestion
The nurse is caring for a client with a ventriculostomy. Which assessment finding demonstrates effectiveness of the ventriculostomy?
Increased ICP is 12 mm Hg. The normal ICP is 0 to 15 mm Hg
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 nurse is caring for a client who requires intracranial pressure (ICP) monitoring. The nurse should be alert for what complication of ICP monitoring?
Infection The catheter for measuring ICP is inserted through a burr hole into a lateral ventricle of the cerebrum, thereby creating a risk of infection.
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
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?
Look for signs of increased intracranial pressure
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?
Meticulous cleanliness
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia?
Monitoring the patency of an indwelling urinary catheter
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?
Observe for any signs of behavioral changes.
The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?
Oliguria and serum hyponatremia
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?
Pulse and blood pressure
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client?
Restricting fluid intake and hydration
Consider the following laboratory values. Identify a critical result for a patient with a TBI.
Serum magnesium of 1.4 mg/dL
A nurse is providing care to a client diagnosed with a spinal cord tumor. Based on the nurse's understanding about treatment for this type of tumor, the nurse would most likely expect to develop a teaching plan related to which therapy?
Surgery
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.
The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first?
The client with a basilar fracture the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull.
The Monro-Kellie hypothesis refers to which of the following?
The dynamic equilibrium of cranial contents
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?
Traction with weights and pulleys
Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?
Transcranial Doppler
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex)
Which are risk factors for spinal cord injury (SCI)? Select all that apply.
Young age Alcohol use Drug abuse
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
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to
dehydrate the brain and reduce cerebral edema.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:
diminished responsiveness.
A client's spouse relates how the client reported a severe headache and then was unable to talk or move their right arm and leg. After diagnostics are completed and the client is admitted to the hospital, when would basic rehabilitation begin?
immediately
A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:
increase the frequency of the catheterizations.
Which are characteristics of autonomic dysreflexia?
severe hypertension, slow heart rate, pounding headache, sweating
A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?
vasodilation
The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing's reflex? Select all that apply.
Apical pulse is 42 beats per minute Blood pressure is 140/38 mmHg Systolic blood pressure is 180 mm/Hg
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.
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?
Autonomic dysreflexia
A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for:
Bleeding from the ears
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP?
Decerebrate posturing and loss of corneal reflex
A patient is admitted to the emergency room with a skull fracture. The nurse notes a blood stain, surrounded by a yellowish ring, on the linens on the stretcher. The patient's respiratory system was stabilized at the site of the accident. Which of the following nursing interventions describes the immediate nursing action that needs to be taken?
Elevate the head of the bed 30 degrees. The head is elevated 30 degrees to reduce ICP and promote spontaneous closure of the leak.
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 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.
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
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. While assessing the client, the nurse expects which of the following findings?
Excessive urine output and decreased urine osmolality
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?
Fever and change in urine clarity
A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?
Flaccid
The staff educator is orientating a nurse new to the neurological ICU when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. What sign or symptom is consistent with this diagnosis?
Hypotension Manifestations of neurogenic shock include decreased blood pressure and heart rate.
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 Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration.
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)
A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?
Lethargy Decreasing level of consciousness is one of the earliest signs of increased intracranial pressure (ICP).
A patient is being cared for after suffering a traumatic brain injury in a motorcycle accident. Since the patient has regained consciousness, the nurse has been prioritizing assessments related to the possibility of increased intracranial pressure (ICP). Assessment for early signs of increased ICP should focus most closely on which of the following parameters?
Level of consciousness (LOC)
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)?
Maintain cerebral perfusion pressure from 50 to 70 mm Hg
A nurse working on a medical-surgical floor walks into a patient's room to find the patient with an altered level of consciousness (LOC). Which of the following actions would be the first priority?
Maintenance of a patent airway
The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?
Mannitol
A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?
Midbrain
A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?
Monro-Kellie
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
Neurologic examination
A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first?
Place in a seated position. Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure.
Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?
Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia.
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 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.
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP?
Rising blood pressure and bradycardia
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?
Risk for injury
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
Which of the following is not a manifestation of Cushing's triad (Cushing reflex)?
Tachycardia Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration.
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
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'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.
A 14-year-old boy was brought to the emergency department (ED) by his father after suffering an apparent concussion during a game. Assessment in the ED confirmed the father's suspicion, and the boy is being discharged home in his father's care. What health education should the nurse provide to the boy's father?
The father should awaken his son every 2 hours during the night.
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?
The patient will be able to ambulate independently. Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?
client maintains mechanical ventilation with minimal mucus accumulation
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?
Body temperature It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage
Which of the following is an early sign of increasing intracranial pressure (ICP)?
Headache
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
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 results from inadequate delivery of nutrients and oxygen to the cells.
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 client's neck in a neutral position (no flexing).
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply.
Maintaining aseptic technique with an intraventricular catheter Administering prescribed antipyretics Frequent oral care
An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
Motor vehicle accidents
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, except for logrolling as needed
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 should the nurse explain differentiates the two disorders?
The first thoracic vertebrae Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.
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:
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).
