Ch. 63

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 evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

Edema to the head with bruising of the mastoid process

Which are risk factors for spinal cord injury (SCI)? Select all that apply.

Young age Alcohol use Drug abuse

Which are characteristics of autonomic dysreflexia?

severe hypertension, slow heart rate, pounding headache, sweating

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 can apply powder under the liner to help with sweating."

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 mL/hr

The earliest sign of serious impairment of brain circulation related to increased ICP is:

A change in consciousness.

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

Absence of reflexes along with flaccid extremities

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?

An intracerebral hematoma

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 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 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

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?

Autonomic dysreflexia

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?

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)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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

Body temperature

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

A client with a spinal cord injury has full head and neck control when the injury is at which level?

C5

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

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).

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

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

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

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.

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

C5

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

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 of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply.

Hemiparesis Coma Decreased reactivity of the pupils Bradycardia

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

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

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

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

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 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

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

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

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.

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.

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

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

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?

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

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.

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

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

Subdural hematoma

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

Neurological level of spinal cord injury refers to which of the following?

The lowest level at which sensory and motor function is normal

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.

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

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply.

Vomiting Weakness on one side of the body Slurred speech

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

Widened pulse pressure

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

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

body temperature

The office nurse is reviewing an 80-year-old female client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. During a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results. Complete the following sentence by choosing from the lists of options. The nurse anticipates that the client has developed _______________ and that ______________________ will be ordered.

chronic subdural hematoma computed tomography (CT) imaging of the brain

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 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.

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