ADV MS Neuro PrepU

The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction?

"I'll check under the liner for blisters and redness." Explanation: The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain.

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

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch?

spasicity

A posttraumatic seizure that is classified as early, occurs within which timeframe?

1 to 7 days of injury Explanation: Posttraumatic seizures are classified as immediate (occurring within 24 hours of injury), early (occurring within 1 to 7 days of injury) or late (occurring more than 7 days following injury).

Which Glasgow Coma Scale score is indicative of a severe head injury?

7 3-15 is range scale

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 Explanation: The nurse should report the presence of yellow drainage, which indicates the presence of infection, at the left pin insertion site.

A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?

Acute

The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation? a)

An area of bruising over the mastoid bone

You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

Autonomic dysreflexia Explanation: Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides.

A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?

Basilar Explanation: Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture.

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

C5

Which of the following is the earliest sign of increasing intracranial pressure (ICP)?

Change in level of consciousness (LOC) Explanation: The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately.

The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful?

Conception is not impaired; the birth process is determined with the physician. Explanation: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate.

While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?

Concussion

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

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?

Epidural

A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family?

Look for signs of increased intracranial pressure

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do?

Maintain a diet for the client that is high in protein, vitamins, and calories.

Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?

Subdural hematoma Explanation: A subdural hematoma is bleeding between the dura mater and arachnoid membrane.

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

T6

Which of the following is not a manifestation of Cushing's Triad?

Tachycardia

The nurse received 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.

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?

body temperature

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion?

contusion

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?

neffective breathing pattern

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. Explanation: 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.

A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient

vomits

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.

• Bradycardia • Hypertension • Bradypnea

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. Explanation: To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities.

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 Explanation: 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.

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.

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.

• Eye opening • Verbal response • Motor response

The nurse is assigned to care for patients with SCI on a rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply.

• Hypertension • Diaphoresis • Nasal congestion

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