week 11, SCI

A nurse on a neurological unit is participating in the care of a female patient who is receiving treatment for a spinal cord injury (SCI) that she experienced 2 weeks ago. The patient's care plan specifies measures to prevent skin breakdown, and the nurse has planned several changes of position during the shift. How should the nurse best reposition this patient?

"Log roll" the patient.

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient? 8 to 15 mm Hg 0 to 10 mm Hg 20 to 30 mm Hg 25 to 40 mm Hg

0 to 10 mm Hg

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

Absence of reflexes along with flaccid extremities

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

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 Male gender Young age Alcohol/drug use

Being an athlete

The causes of acquired seizures include what? (Mark all that apply.) Cerebrovascular disease Metabolic and toxic conditions Hypernatremia Brain tumor Drug and alcohol withdrawal

Cerebrovascular disease Metabolic and toxic conditions Brain tumor Drug and alcohol withdrawal

Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply.

Eating Breathing Transferring to a wheelchair Writing

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

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

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 Bradycardia Decreased reactivity of the pupils 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

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 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 public health nurse is participating in a health promotion workshop and is teaching a group of high school students how to respond if a person suffers an apparent spinal cord injury. The nurse should instruct participants to:

Keep the victim's head in a neutral position at all times.

A public health nurse has formed a partnership with an advocacy group that acts on behalf of individuals who have experienced spinal cord injuries (SCIs). Health promotion efforts are being planned with a knowledge that the incidence of SCIs varies widely between demographic groups. What population has the highest incidence of spinal cord injuries?

Males between ages 16 and 30

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man 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

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

Motor vehicle crashes

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

A client with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this client? Select all that apply.

Orthostatic hypotension Autonomic dysreflexia DVT

A client with neurological 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

What drug, prescribed for Parkinson's disease, has neuroprotective properties? Amantadine (Symmetrel) Selegiline (Eldepryl) Bromocriptine (Parlodel) Levodopa (Larodopa)

Selegiline (Eldepryl)

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

Spinal shock

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

Spinal shock

Which are possible long-term complications of spinal cord injury? Select all that apply.

autonomic dysreflexia respiratory infection

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 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 of the following is a clinical manifestation of pupillary changes that indicate increasing ICP? Pupils are equal and normally reactive. Pupils are unequal in diameter. Pupils are showing progressive dilation. Pupils are fixed and dilated.

Pupils are showing progressive dilation.

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.

Which assessment finding is most important in determining nursing care for a client with bacterial meningitis? Select all that apply. Cloudy cerebral spinal fluid Pain and stiffness of the extremities Purpura of hands and feet Low white blood cell (WBC) count Low red blood cell (RBC) count Low antidiuretic hormone (ADH) levels

Cloudy cerebral spinal fluid Purpura of hands and feet

A client has developed autonomic dysreflexia and all measures to identify a trigger have been unsuccessful. What medication would the nurse provide as ordered by the healthcare provider to decrease the blood pressure?

Hydralazine hydrochloride IV, administered slowly

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 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.

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

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 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)

The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?

Sympathetic nervous system

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

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 Venous pooling Tachypnea Hypothermia

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

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question? Giving him a barbiturate Placing him on mechanical ventilation Performing a lumbar puncture Elevating the head of his bed

Performing a lumbar puncture

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.

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

T6

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client?

They have the beginning of a pressure sore.

An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion? To decrease cerebral arterial pressure To avoid impeding venous outflow To prevent flexion contractures To prevent aspiration of stomach contents

To avoid impeding venous outflow

A nurse is caring for a client with a history of severe migraines. The client has a medical history that includes asthma, gastroesophageal reflux disease, and three pregnancies. Which medication does the nurse anticipate the physician will order for the client's migraines? Verapamil (Calan) Metoprolol (Lopressor) Amiodarone (Cordarone) Captopril (Coreg)

Verapamil (Calan)

Which of the following assessment findings would indicate an increasing intracranial pressure (ICP) in a client with head trauma? Select all that apply. Stiff neck Generalized pain Glasgow Coma Scale of 15 Elevated systolic blood pressure Brisk pupil response Wide pulse pressure

Elevated systolic blood pressure Wide pulse pressure

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 Subdural Intracerebral Contusion

Epidural

A 36-year-old male patient is preparing for discharge from the hospital to a rehabilitative facility 4 weeks after he suffered a spinal cord injury (SCI) during a workplace accident. The hospital nurse should be aware that the primary focus of this coming phase of the patient's recovery will be:

Providing him with the skills to perform as many activities of daily living (ADLs) as possible

A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: loss of the sensation of pain and temperature on the side opposite the injury. loss of motor power and sensation in the upper extremities. preservation of a sense of touch below the level of the lesion. loss of motor power, pain, and temperature sensation below the level of the lesion.

loss of motor power and sensation in the upper extremities.

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

A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician?

A small amount of yellow drainage at the left pin insertion site

Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Administering prescribed antipyretics Elevating the head of the bed to 90 degrees Maintaining aseptic technique with an intraventricular catheter Encouraging deep breathing and coughing every 2 hours Frequent oral care

Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care

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.

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

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter? Fluid volume deficit Risk for infection Ineffective cerebral tissue perfusion Risk for injury

Ineffective cerebral tissue perfusion

Which is the most common cause of spinal cord injury (SCI)?

Motor vehicle crashes

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

The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurological exam

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? Excessive urine output and decreased urine osmolality Oliguria and serum hyponatremia Oliguria and serum hyperosmolarity Excessive urine output and serum hyponatremia

Oliguria and serum hyponatremia

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 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

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

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 first thoracic vertebrae

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.

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

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? Decerebrate Decorticate Flaccid Rigid

Flaccid

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

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

Respiratory arrest Spinal shock

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