Chapter 39: Caring for Clients with Head and Spinal Cord Trauma
At which of the following spinal cord injury levels does the patient have full head and neck control? C4 C2 C5 C3
C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? -Care of the cervical collar -Techniques for restoring nerve function -Technique for performing neck ROM exercises -Home assessment of ABGs
Care of the cervical collar Explanation: Prior to discharge, the nurse should assess the client's use and care of the cervical collar. Neck ROM exercises would be contraindicated and ABGs cannot be assessed in the home. Nerve function is not compromised by a discectomy.
The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on the head during a play. While awaiting an ambulance, what action should the nurse perform? -Ensure that the player is not moved. -Perform a rapid assessment of the player's range of motion. -Assess the player's reflexes. -Obtain the player's vital signs, if possible.
Ensure that the player is not moved. Explanation: At the scene of the injury, the client must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the client's vital signs. It would be inappropriate to test ROM or reflexes.
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 manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? -Place the client in the Trendelenburg position. -Prepare an ice bath to lower core body temperature. -Prepare to transfuse packed red blood cells. -Prepare for interventions to increase the client's BP.
Prepare for interventions to increase the client's BP. Explanation: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? -Tetraplegia -Cardiogenic shock -Paraplegia -Spinal shock
Spinal shock Explanation: Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI..
The nurse is concerned that a client with a traumatic brain injury is developing an endocrine disorder. Which assessment will the nurse complete for this client? Select all that apply. -Urine acetone -Intake and output -Blood glucose -Hemoglobin -Serum electrolytes
-Blood glucose -Urine acetone -Intake and output -Serum electrolytes Explanation: Brain damage can produce metabolic and hormonal dysfunctions. Endocrine function is evaluated by monitoring blood glucose, urine acetone, intake and output, and serum electrolytes. Hemoglobin level is not a concern when monitoring alterations in a client's endocrine function.
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 stroke -computed tomography (CT) imaging of the brain Explanation: This client has had a prior head trauma with a negative imaging scan. Prior head trauma can lead to the development of a chronic subdural hematoma, which presents with symptoms such as severe headache, mental deterioration, focal neurologic changes, personality changes, and/or symptoms that the client is having a stroke. There is no indication that the client had follow-up imaging based on the prior head trauma, which should be included in protocol management of head injuries. Prior head trauma can lead to the development of a chronic subdural hematoma. Based on the clinical presentation of a severe headache, this is the most likely clinical diagnosis. Based on the clinical presentation, follow-up imaging is indicated to confirm the presence of a chronic subdural hematoma, which can occur following a recent head trauma. Because the head trauma occurred a few months ago, an acute finding would have presented earlier, at the time of injury. The differential diagnosis of chronic subdural hematoma includes a stroke but there is insufficient clinical evidence to support this finding. An electrocardiogram (ECG) is not indicated at this time because there is no provided clinical evidence of any cardiac abnormalities. Coagulation studies are not indicated at this time because the priority is to obtain an imaging study.
The nurse provides care for a client who is experiencing cerebrospinal fluid (CSF) drainage due to a skull fracture. When managing the CSF drainage, which action(s) by the nurse is appropriate? Select all that apply. Pinch the client's nose to stop the flow of the drainage. Allow the fluid to flow freely onto porous gauze. Tilt the client's back to prevent the drainage of the fluid. Plug the orifice that is draining the fluid. Send the fluid to the laboratory for a culture and sensitivity (C&S).
Allow the fluid to flow freely onto porous gauze. Explanation: If CSF drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. It is not appropriate to tilt the head back to prevent the drainage of the fluid nor is it appropriate to tell the client to pinch the nose to stop the flow of the drainage. There is no reason to send the fluid to the laboratory for a C&S unless an infection is suspected.
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? -Administering an antifibrinolytic agent -Placing the patient on a fluid restriction -Applying thigh-high elastic stockings -Assisting the patient with passive range of motion exercises
Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation.
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? -Administering an antifibrinolytic agent -Placing the patient on a fluid restriction -Assisting the patient with passive range of motion exercises -Applying thigh-high elastic stockings
Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation.
A nurse is planning discharge education for a client who underwent a cervical discectomy. What strategies would the nurse assess that would aid in planning discharge teaching? -Techniques for restoring nerve function -Care of the cervical collar -Technique for performing neck ROM exercises -Home assessment of ABGs
Care of the cervical collar Explanation: Prior to discharge, the nurse should assess the client's use and care of the cervical collar. Neck ROM exercises would be contraindicated and ABGs cannot be assessed in the home. Nerve function is not compromised by a discectomy.
A halo sign is indicative of which of the following complication of brain injury? -Seizure -Cerebral edema -Cerebrospinal fluid (CSF) leak -Ischemia
Cerebrospinal fluid (CSF) leak Explanation: A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.
A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client? -Intubation and mechanical ventilation -Seizure prophylaxis and prevention -Fluid and electrolyte maintenance -Cervical and spinal immobilization
Cervical and spinal immobilization Explanation: Any client with a head injury is presumed to have a cervical spine injury until proven otherwise. The client is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI (spinal cord injury) documented. This client's x-rays were pending so spinal precautions should be maintained and are the priority. Primary injury to the brain is defined as the consequence of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries. The greatest opportunity for decreasing TBI (traumatic brain injury) is the implementation of prevention strategies. Treatment for clients with suspected increased intracranial pressure (ICP) also includes ventilator support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and management of pain and anxiety. Clients who are comatose are intubated and mechanically ventilated to ensure adequate oxygenation and to protect their airway. No information was provided on current ICP. The client was not fully orientated so he/she was transferred to the ICU for closer monitoring.
The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications? -Hematoma at the surgical site -Renal trauma -Vertebral fracture -Scoliosis
Hematoma at the surgical site Explanation: Based on all the assessment data, the potential complications of discectomy may include hematoma at the surgical site, resulting in cord compression and neurologic deficit and recurrent or persistent pain after surgery. Renal trauma and fractures are unlikely; scoliosis is a congenital malformation of the spine.
The nurse is caring for a client who is scheduled for a cervical discectomy the following day. During health education, the client should be made aware of what potential complications? -Renal trauma -Vertebral fracture -Scoliosis -Hematoma at the surgical site
Hematoma at the surgical site Explanation: Based on all the assessment data, the potential complications of discectomy may include hematoma at the surgical site, resulting in cord compression and neurologic deficit and recurrent or persistent pain after surgery. Renal trauma and fractures are unlikely; scoliosis is a congenital malformation of the spine.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? -Cushing's response -Autoregulation -Monro-Kellie hypothesis -Herniation
Herniation Explanation: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
The nurse caring for a client diagnosed with a spinal cord injury notes early signs and symptoms of atrophy. Which of the following is the most appropriate nursing action? -Collaborate with the physical therapist and immobilize the client's extremities temporarily. -Limit the amount of assistance provided with ADLs. -Increase the frequency of passive range-of-motion (ROM) exercises. -Educate the client about the importance of frequent position changes.
Increase the frequency of passive range-of-motion (ROM) exercises. Explanation: To prevent atrophy, ROM exercises must be done at least four times a day, and care is taken to stretch the Achilles tendon with exercises. The client is repositioned frequently and is maintained in proper body alignment whether in bed or in a wheelchair. The client must be repositioned by caregivers, not just taught about repositioning. It is inappropriate to limit assistance for the sole purpose of preventing disuse syndrome.
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? -Disturbed thought processes related to brain injury -Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction -Ineffective cerebral tissue perfusion related to increased intracranial pressure -Ineffective airway clearance related to brain injury
Ineffective airway clearance related to brain injury Explanation: Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.
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? -Position the client in a high-Fowler position when in bed. -Administer NSAIDs as prescribed. -Support the knees with a pillow when the client is in bed. -Perform passive ROM exercises as prescribed.
Perform passive ROM exercises as prescribed. Explanation: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the client's risk of muscle spasticity.
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? -Support the knees with a pillow when the client is in bed. -Administer NSAIDs as prescribed. -Perform passive ROM exercises as prescribed. -Position the client in a high-Fowler position when in bed.
Perform passive ROM exercises as prescribed. Explanation: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the client's risk of muscle spasticity.
A client, diagnosed with cancer of the lung, has just been told the cancer has metastasized to the brain. What change in health status would the nurse attribute to the client's metastatic brain disease? -Chronic pain -Personality changes -Respiratory distress -Fixed pupils
Personality changes Explanation: Neurologic signs and symptoms include headache, gait disturbances, visual impairment, personality changes, altered mentation (memory loss and confusion), focal weakness, paralysis, aphasia, and seizures. Pain, respiratory distress, and fixed pupils are not among the more common neurologic signs and symptoms of metastatic brain disease.
A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? Asses the skin for areas of pressure. Place in a seated position. Palpate the bladder for distention. Examine the rectum for a fecal mass.
Place in a seated position. Explanation: 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. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.
A client with a T4-level spinal cord injury (SCI) 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? -Notify the physician. -Apply antiembolic stockings. -Lay the client flat. -Place the client in a sitting position.
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
A client with a T4-level spinal cord injury (SCI) 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 the client in a sitting position. -Lay the client flat. -Notify the physician. -Apply antiembolic stockings.
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
A nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. The nurse's care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. Which are the most likely possible causes of death for this client? Pneumonia, pulmonary embolism, and sepsis Oxygen toxicity in paralytic ileus and electrolyte imbalances Seizures, osteomyelitis, and urinary tract infections Cardiac tamponade, hypoxia, and malnutrition
Pneumonia, pulmonary embolism, and sepsis Explanation: The nurse is assisting the client with assisted coughing to prevent pneumonia. Pulmonary infections are managed and prevented by frequent coughing, turning, and deep breathing exercises and chest physiotherapy; aggressive respiratory care and suctioning of the airway if a tracheostomy is present; assisted coughing as needed; and adequate hydration. Low-dose anticoagulation therapy usually is initiated to prevent DVT (deep vein thrombosis) and PE (pulmonary embolism), along with the use of anti-embolism stockings or sequential pneumatic compression devices (SCDs). Pressure injuries have the potential complication of sepsis, osteomyelitis, and fistulas. All of the other listed causes may occur in clients with SCI but are not the main causes of death. The interventions discussed above directly assist in the prevention of pneumonia, pulmonary embolism osteomyelitis and sepsis.
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? -Empty the bladder immediately. -Examine the rectum for a fecal mass. -Raise the head of the bed and place the patient in a sitting position. -Examine the skin for any area of pressure or irritation.
Raise the head of the bed and place the patient in a sitting position. Explanation: The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? -Subdural hematoma -Intracerebral hemorrhage -Extradural hematoma -Epidural hematoma
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural 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 -Urinary output increase from 40 to 55 mL/hr -Pulse oximetry decrease from 99% to 97% room air -Heart rate decrease from 100 to 90 bpm
Temperature increase from 98.0°F to 99.6°F Explanation: Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
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 analgesia regimen was recently changed. -The client's urinary catheter became occluded. -The client was not repositioned during the night shift. -The client received a blood transfusion.
The client's urinary catheter became occluded. Explanation: A distended bladder is the most common cause of autonomic dysreflexia. Infrequent positioning is a less likely cause, although pressure ulcers or tactile stimulation can cause it. Changes in medications or blood transfusions are unlikely causes.
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)? -Widened pulse pressure -Decreased body temperature -Increased pulse -Decreased respirations
Widened pulse pressure Explanation: Additional signs of increasing ICP include increasing systolic blood pressure, bradycardia, rapid respirations, and rapid rise in body temperature. Bradycardia, slowing of the pulse, is an indication of increasing ICP in the head-injured patient. Rapid respiration is an indication of increasing ICP in the head-injured patient. A rapid rise in body temperature is regarded as unfavorable because hyperthermia may indicate brain stem damage, a poor prognostic sign.
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 Explanation: 20/15 × 60 = 80 mL/hr
A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? Assessing all body surfaces and documenting skin integrity every 8 hours Turning and repositioning the client every 6 hours Assisting the client to get out of bed to a chair four times a day Providing skin care with barrier care ointments once a day
Assessing all body surfaces and documenting skin integrity every 8 hours Explanation: Clients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Specific nursing measures include the following: Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the client should occur every 2 hours. Skin care should be done every 4 hours and includes more than applying an ointment. Other interventions include keeping the skin dry, offloading bony prominences and with pillows or wedge devices. Since this client is unconscious; assisting the client to get out of bed needs his/her cooperation which is not possible. It should also be three times a day and not four.
A client with a spinal cord injury has full head and neck control when the injury is at which level? C1 C2 to C3 C4 C5
C5 Explanation: At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? -Epidural -Intracerebral -Subdural -Diffuse axonal
Epidural Explanation: An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.
A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client reports pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? -In a flat side-lying position -In the high Fowler position -In the reverse Trendelenburg position -In the Trendelenburg position
In a flat side-lying position Explanation: After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. The Fowler position, Trendelenburg position, and reverse Trendelenburg position are inappropriate for this client because they would result in increased pain and complications.
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 is the only device that can be applied for stabilization of a spinal fracture. -The patient can remove it as needed. -It allows for stabilization of the cervical spine along with early ambulation. -It is less bulky and traumatizing for the patient to use.
It allows for stabilization of the cervical spine along with early ambulation. Explanation: Halo devices provide immobilization of the cervical spine while allowing early ambulation.
Which of the following would the nurse recognize as being the least likely reason for the procedure shown in the accompanying image? -To confirm a skull fracture -To evacuate a hematoma -To aspirate a brain abscess -To make a bone flap in the skull
To confirm a skull fracture Explanation: The image shows the use of burr holes, which are used when neurosurgical procedures are needed to make a bone flap in the skull, aspirate a brain abscess, or evacuate a hematoma. Skull fracture would be ruled out or confirmed through skull radiography.
A client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of their urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Urinary catheters should not remain in place for more than 7 days. Urinary function is permanently lost following an SCI. Overuse of urinary catheters can exacerbate nerve damage. Urinary retention can have serious consequences in clients with SCIs.
Urinary retention can have serious consequences in clients with SCIs. Explanation: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.
A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? -Fluid resuscitation -Administration of inotropic drugs -Preparation for emergency craniotomy -Watchful waiting and close monitoring
Watchful waiting and close monitoring Explanation: Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the client is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.
A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is: -a result of arterial bleeding into the space above the dura. -a result of venous bleeding into the space above the dura. -a result of venous bleeding into the space below the dura. -bleeding within the brain.
a result of venous bleeding into the space below the dura. Explanation: A subdural hematoma is a result of venous bleeding into the space below the dura and is further classified as acute, subacute, and chronic according to the rate of neurologic changes. An epidural hematoma results from arterial bleeding into the space above the dura. Bleeding within the brain describes an intracerebral hematoma.
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 -intracerebral -subacute -chronic
acute Explanation: Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.
A client had a long and successful ice 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: -cerebral hematoma. -chronic traumatic encephalopathy. -concussion. -contusion.
chronic traumatic encephalopathy. Explanation: Chronic traumatic encephalopathy can occur after experiencing cumulative and sustained concussions. Long-term effects such as dementia, Parkinson's disease, and early onset Alzheimer's may occur.
A nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client? -Third-spacing and hyperthermia -Tachycardia and agitation - Bradycardia and hypertension -Respiratory distress and projectile vomiting
Bradycardia and hypertension Explanation: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection ("goose bumps"), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing.
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)? -Intracerebral -Contusion -Epidural -Subdural
Epidural Explanation: Symptoms of the epidural hematoma are caused by the expanding hematoma. Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval). Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid.
A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? -Preparation for emergency craniotomy -Fluid resuscitation -Watchful waiting and close monitoring -Administration of inotropic drugs
Watchful waiting and close monitoring Explanation: Nondepressed skull fractures generally do not require surgical treatment; however, close observation of the client is essential. A craniotomy would not likely be needed if the fracture is nondepressed. Even if treatment is warranted, it is unlikely to include inotropes or fluid resuscitation.
A client had a long and successful ice 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: -cerebral hematoma. -contusion. -concussion. -chronic traumatic encephalopathy.
chronic traumatic encephalopathy. Explanation: Chronic traumatic encephalopathy can occur after experiencing cumulative and sustained concussions. Long-term effects such as dementia, Parkinson's disease, and early onset Alzheimer's may occur.
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: -ALS. -a blood clot. -chronic traumatic encephalopathy. -stroke.
chronic traumatic encephalopathy. Explanation: When concussions occur repetitively, they can result in a form of neurode generation known as chronic traumatic encephalopathy.
A client was involved in a motor-vehicle collision. At the emergency department, diagnostic tests indicated a brain contusion. The client was admitted to the ICU for observation. What factor determines the magnitude of the signs and symptoms? -location of head wound -seatbelt use -loss of consciousness -degree of head velocity
degree of head velocity Explanation: Signs and symptoms vary depending on the severity of the blow and the degree of head velocity.
After undergoing surgery for removal of a spinal cord tumor, the client is placed in the side-lying position. The nurse places a pillow between the client's knees to prevent: -cerebrospinal fluid (CSF) leakage. -pressure injury. -body misalignment. -knee flexion.
knee flexion. Explanation: The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. Placement of a pillow between the knees of the client in a side-lying position helps to prevent extreme knee flexion. The pillow does not prevent CSF leakage, pressure injury, or body misalignment.
A client who has been severely beaten is admitted to the emergency department. The nurse suspects a basilar skull fracture after assessing: -pupillary changes. -motor loss in the legs that exceeds that in the arms. -nuchal rigidity and Kernig's sign. -raccoon's eyes and Battle sign.
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. Nuchal rigidity and Kernig's sign are associated with meningitis. Motor loss in the legs that exceeds that in the arms suggests central cord syndrome. Pupillary changes are common in skull fractures with associated meningeal artery bleeding and uncal herniation.
Which are characteristics of autonomic dysreflexia? -severe hypertension, tachycardia, blurred vision, dry skin -severe hypotension, tachycardia, nausea, flushed skin -severe hypotension, slow heart rate, anxiety, dry skin -severe hypertension, slow heart rate, pounding headache, sweating
severe hypertension, slow heart rate, pounding headache, sweating Explanation: Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
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 -reports generalized weakness. -sleeps for short periods of time. -vomits. -reports a headache.
vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
A nurse has received an unconscious client with a traumatic brain injury (TBI). The nurse is concerned about the client's skin integrity and implements interventions to prevent pressure injuries. Which action should the nurse implement during the shift? Assisting the client to get out of bed to a chair four times a day Assessing all body surfaces and documenting skin integrity every 8 hours Providing skin care with barrier care ointments once a day Turning and repositioning the client every 6 hours
Assessing all body surfaces and documenting skin integrity every 8 hours Explanation: Clients with TBI often require assistance in turning and positioning because of immobility or unconsciousness. Prolonged pressure on the tissues decreases circulation and leads to tissue necrosis. Specific nursing measures include the following: Assessing all body surfaces and documenting skin integrity every 8 hours. Turning and repositioning the client should occur every 2 hours. Skin care should be done every 4 hours and includes more than applying an ointment. Other interventions include keeping the skin dry, offloading bony prominences and with pillows or wedge devices. Since this client is unconscious; assisting the client to get out of bed needs his/her cooperation which is not possible. It should also be three times a day and not four.
Which instructions should the nurse give a client who has been given a skeletal muscle relaxant for a herniated intervertebral disk? -Dizziness is an unexpected side effect. -Muscle relaxants are not known to cause drowsiness. -Avoid driving or operating equipment. -Avoid physical exertion.
Avoid driving or operating equipment. Explanation: Clients taking a muscle relaxant may experience drowsiness and dizziness. They require assistance with ambulatory activities and should not drive or operate equipment. Physical exertion is not a contraindication when taking a muscle relaxant.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? -To increase cerebral perfusion pressure -Because hypoxemia can create or worsen a neurologic deficit of the spinal cord -So that the patient will not have a respiratory arrest -To prevent secondary brain injury
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
A client is admitted reporting low back pain. How will the nurse best determine if the pain is related to a herniated lumbar disc? -Have the client lie on the back and lift the leg, keeping it straight. -Ask if the client can walk. -Ask the client if there is pain on ambulation. -Ask if the client has had a bowel movement.
Have the client lie on the back and lift the leg, keeping it straight. Explanation: A client who can lie on the back and raise a leg in a straight position will have pain radiating into the leg if there is a herniated lumbar disc. This action stretches the sciatic nerve. The client may also have muscle weakness and decreased tendon reflexes and sensory loss. The client should still be able to walk, and have bowel movements, so this assessment will not assist the nurse to confirm the diagnosis. Pain on ambulation is also not specific to this condition.
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: -Ischemic cerebrovascular accident (CVA) -Brain tissue necrosis -Increased intracranial pressure (ICP) -Decreased intravascular volume
Increased intracranial pressure (ICP) Explanation: The pathological effects of an epidural hematoma are primarily a result of the consequent increase in ICP. Blood loss, ischemia, and necrosis are not the primary sequelae of an epidural hematoma.
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? -Position the client in a high-Fowler position when in bed. -Administer NSAIDs as prescribed. -Perform passive ROM exercises as prescribed. -Support the knees with a pillow when the client is in bed.
Perform passive ROM exercises as prescribed. Explanation: Passive ROM exercises can prevent muscle spasticity following SCI. NSAIDs are not used for this purpose. Pillows and sitting upright do not directly address the client's risk of muscle spasticity.
A 13-year-old was brought to the ED after being hit in the head by a baseball and is subsequently diagnosed with a concussion. Which assessment finding would rule out discharging the client? -The client reports pain at the site where the ball hits his head. -The client reports a headache. -The client is visibly fatigued. -The client's speech is slightly slurred.
The client's speech is slightly slurred. Explanation: Slurred speech would indicate a need for further assessment and observation due to the possibility of more serious trauma. Localized pain, a headache and fatigue are consistent with a concussion and do not necessarily require further intervention.
The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? -Babinski sign -Kernig's sign -Battle's sign -Brudzinski's sign
Battle's sign Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. A positive Kernig's and positive Brudzinski's sign indicate meningeal irritation. Babinski's sign (reflex) is indicative of central nervous system disease in the corticospinal tract.
The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? -Kernig's sign -Brudzinski's sign -Babinski sign -Battle's sign
Battle's sign Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. A positive Kernig's and positive Brudzinski's sign indicate meningeal irritation. Babinski's sign (reflex) is indicative of central nervous system disease in the corticospinal tract.
At which of the following spinal cord injury levels does the patient have full head and neck control? C2 C4 C3 C5
C5 Explanation: At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? -Subdural -Epidural -Cerebral -Intracerebral
Subdural Explanation: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull.
A client's family is trying to understand the client's diagnosis of an acute subdural hematoma. The nurse would best explain the condition by stating that a subdural hematoma is: -a result of venous bleeding into the space below the dura. -bleeding within the brain. -a result of arterial bleeding into the space above the dura. -a result of venous bleeding into the space above the dura
a result of venous bleeding into the space below the dura. Explanation: A subdural hematoma is a result of venous bleeding into the space below the dura and is further classified as acute, subacute, and chronic according to the rate of neurologic changes. An epidural hematoma results from arterial bleeding into the space above the dura. Bleeding within the brain describes an intracerebral hematoma.
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 -sleeps for short periods of time. -vomits. -reports a headache. -reports generalized weakness.
vomits. Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
A client reports experiencing lower back pain after lifting a heavy box. Which symptom(s) would lead the nurse to suspect lumbar nerve compression? Select all that apply. -Pain occurs when lying supine in bed. -Pain increases with coughing. -Pain in the buttocks extends down the leg. -Pain is alleviated by walking. -Pain is alleviated with sitting.
-Pain occurs when lying supine in bed. -Pain increases with coughing. -pain in the buttocks extends down the leg. Explanation: When a herniated disk in the lumbar region compresses the sciatic nerve, the client describes feeling pain down the buttocks and into the posterior thigh and leg. If a nerve in the lumbar or sacral area is affected, the client experiences pain when lying supine and lifting the leg without bending the knee. The pain increases when straining, coughing, or lifting a heavy object. Walking and sitting become difficult.
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. -Headache -Slurred speech -Sleeps for short periods of time -Vomiting -Weakness on one side of the body
-Slurred speech -Vomiting -Weakness on one side of the body Explanation: Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately.
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? -Injuries due to a fall -Acts of violence -Sports-related injuries -Motor vehicle accidents
Motor vehicle accidents Explanation: The most common cause of SCI is motor vehicle accidents, which account for 42% of SCI. Violence-related injuries account for 15% of SCIs, with falls causing 26.7%, and sports-related injuries causing 7.6% of SCIs
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? -Mannitol -Phenobarbital -Baclofen -Dexamethasone
Baclofen Explanation: Baclofen is classified as an antispasmodic agent in the treatment of muscle spasms related to spinal cord injury. Decadron is an anti-inflammatory medication used to decrease inflammation in both SCI and head injury. Mannitol is used to decrease cerebral edema in clients with head injury. Phenobarbital is an anticonvulsant that is used in the treatment of seizure activity.
A halo sign is indicative of which of the following complication of brain injury? -Cerebral edema -Seizure -Ischemia -Cerebrospinal fluid (CSF) leak
Cerebrospinal fluid (CSF) leak Explanation: A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? -Ineffective cerebral tissue perfusion related to increased intracranial pressure -Disturbed thought processes related to brain injury -Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction -Ineffective airway clearance related to brain injury
Ineffective airway clearance related to brain injury Explanation: Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? -Epidural hematoma -Extradural hematoma -Subdural hematoma -Intracerebral hemorrhage
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? -Subdural -Intracerebral hemorrhage -Extradural hematoma -Epidural hematoma
Subdural hematoma Explanation: A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
Which of the following is a sign of increasing ICP? -Decreasing systolic blood pressure -Widening pulse pressure -Tachycardia -Bradypnea
Widening pulse pressure Explanation: Signs of increasing ICP include slowing of the heart rate, increasing systolic blood pressure, and widening pulse pressure.
The nurse is caring for a client postoperatively from a spinal tumor resection. The nurse assesses that the client has partial paralysis. What anticipated problems should the nurse include in the client's care plan? Select all that apply. -Risk for impaired physical mobility -Risk for powerlessness -Risk for injury -Risk for sexual dysfunction -Risk for knowledge deficit
-Risk for impaired physical mobility -Risk for powerlessness -Risk for injury -Risk for knowledge deficit Explanation: The change in the client's muscle strength will effect the client's ability to carry out activities that he or she was once used to being able to perform independently. Due to the partial paralysis, the client is now at risk for impaired physical mobility related to a decreased range of motion. The client is at risk for injury due to a possible unsteady gait. The development of partial paralysis is a loss for the client, and there is the potential for feelings of powerlessness related to inability to control situation and being dependent on others. It is not likely that the nurse has been able to accurately assess sexual dysfunction. Not all clients with partial paralysis experience sexual dysfunction because this is dependent on the extent of spinal injury or nerve compression. Given that teaching is needed, it implies that there is a knowledge deficit.
The nurse provides care for a client who is experiencing cerebrospinal fluid (CSF) drainage due to a skull fracture. When managing the CSF drainage, which action(s) by the nurse is appropriate? Select all that apply. Allow the fluid to flow freely onto porous gauze. Plug the orifice that is draining the fluid. Send the fluid to the laboratory for a culture and sensitivity (C&S). Pinch the client's nose to stop the flow of the drainage. Tilt the client's back to prevent the drainage of the fluid.
Allow the fluid to flow freely onto porous gauze. Explanation: If CSF drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. It is not appropriate to tilt the head back to prevent the drainage of the fluid nor is it appropriate to tell the client to pinch the nose to stop the flow of the drainage. There is no reason to send the fluid to the laboratory for a C&S unless an infection is suspected.
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? -Temporal skull fracture -Basilar skull fracture -Occipital skull fracture -Frontal skull fracture
Basilar skull fracture Explanation: A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client reports pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? -In the reverse Trendelenburg position -In a flat side-lying position -In the high Fowler position -In the Trendelenburg position
In a flat side-lying position Explanation: After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. The Fowler position, Trendelenburg position, and reverse Trendelenburg position are inappropriate for this client because they would result in increased pain and complications.
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? -Epidural hemorrhage -Hypovolemia -Spinal shock -Hypertensive emergency
Spinal shock Explanation: In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function.
A client is admitted to the neurologic ICU with a C3 spinal cord injury (SCI). When writing the plan of care, which of the following issues would the nurse prioritize in the immediate care of this client? -Ineffective breathing patterns related to weakness of the intercostal muscles -Risk for impaired skin integrity related to immobility and sensory loss -Impaired physical mobility related to loss of motor function -Urinary retention related to inability to void spontaneously
Ineffective breathing patterns related to weakness of the intercostal muscles Explanation: An issue related to breathing pattern would be the priority for this client. A C3 SCI will require ventilatory support, due to the diaphragm and intercostals being affected. The other nursing diagnoses would be used in the care plan, but not designated as a higher priority than ineffective breathing patterns.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what? -Injuries due to a fall -Motor vehicle accidents -Acts of violence -Sports-related injuries
Motor vehicle accidents Explanation: The most common causes of SCIs are motor vehicle crashes (38%), followed by falls (31%), violence (15%), and sports (12%).
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. Blood pressure is 140/38 mmHg Urine output over 100 mL/hr Systolic blood pressure is 180 mm/Hg Weakness on one side of the body Apical pulse is 42 beats per minute
Apical pulse is 42 beats per minute Blood pressure is 140/38 mmHg Systolic blood pressure is 180 mm/Hg Explanation: Signs of increasing intracranial pressure and Cushing's reflex include bradycardia, widening pulse pressure, elevated systolic blood pressure, and irregular respirations. Badycardia is a heart or apical rate below 50. A widening pulse pressure is typically defined as a large or wide difference between the two blood pressure readings (systolic and diastolic pressure). Widening pulse pressure readings are present when the difference is greater than 60. In this instance the difference between 140 and 38 is 102. Elevated systolic blood pressure and/or hypertension generally have readings above 140 mm/Hg. Urine output is not an indicator for Cushing's reflex. Weakness on one side of the body or hemiparesis is a finding associated with a stroke.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? -So that the patient will not have a respiratory arrest -To prevent secondary brain injury -To increase cerebral perfusion pressure -Because hypoxemia can create or worsen a neurologic deficit of the spinal cord
Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Explanation: Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
A 35-year-old client is being admitted to the intensive care unit (ICU) for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. The client sustained a fall from a roof, and x-rays are pending. The nurse would anticipate which supportive priority measures for this client?
Cervical and spinal immobilization Explanation: Any client with a head injury is presumed to have a cervical spine injury until proven otherwise. The client is transported from the scene of the injury on a board with the head and neck maintained in alignment with the axis of the body. A cervical collar should be applied and maintained until cervical spine x-rays have been obtained and the absence of cervical SCI (spinal cord injury) documented. This client's x-rays were pending so spinal precautions should be maintained and are the priority. Primary injury to the brain is defined as the consequence of direct contact to the head/brain during the instant of initial injury, causing extracranial focal injuries. The greatest opportunity for decreasing TBI (traumatic brain injury) is the implementation of prevention strategies. Treatment for clients with suspected increased intracranial pressure (ICP) also includes ventilator support, seizure prevention, fluid and electrolyte maintenance, nutritional support, and management of pain and anxiety. Clients who are comatose are intubated and mechanically ventilated to ensure adequate oxygenation and to protect their airway. No information was provided on current ICP. The client was not fully orientated so he/she was transferred to the ICU for closer monitoring.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? -Herniation -Autoregulation -Monro-Kellie hypothesis -Cushing's response
Herniation Explanation: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? -Blood vessels dilate circulating blood. -Venous congestion occurs causing peripheral edema. -Herniation occurs through the foramen magnum. -Additional inflammation occurs in the brain.
Herniation occurs through the foramen magnum. Explanation: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern.
A client has just returned to the unit from the PACU after surgery for a tumor within the spine. The client reports pain. When positioning the client for comfort and to reduce injury to the surgical site, the nurse will position to client in what position? -In the reverse Trendelenburg position -In the high Fowler position -In the Trendelenburg position -In a flat side-lying position
In a flat side-lying position Explanation: After spinal surgery, the bed is usually kept flat initially. The side-lying position is usually the most comfortable because this position imposes the least pressure on the surgical site. The Fowler position, Trendelenburg position, and reverse Trendelenburg position are inappropriate for this client because they would result in increased pain and complications.
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: -Increasing intracranial pressure (ICP) -Leakage of cerebrospinal fluid (CSF) -Meningitis -An epidural hematoma
Leakage of cerebrospinal fluid (CSF) Explanation: In patients with a skull fracture, a halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. This finding is not specifically indicative of meningitis, increased ICP or an epidural hematoma.
A 37-year-old client is brought to the clinic by the spouse because the client is experiencing loss of motor function and sensation. The health care provider suspects the client has a spinal cord tumor and hospitalizes the client for diagnostic testing. In light of the need to rule out spinal cord compression from a tumor, the nurse will most likely prepare the client for what test? -Ultrasound -Anterior-posterior x-ray -Lumbar puncture -MRI
MRI Explanation: The MRI scan is the most commonly used diagnostic procedure. It is the most sensitive diagnostic tool that is particularly helpful in detecting epidural spinal cord compression and vertebral bone metastases.
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 injury? -Administer opioids PRN as prescribed. -Restrain the client as ordered. -Arrange for friends and family members to sit with the client. -Pad the side rails of the client's bed.
Pad the side rails of the client's bed. Explanation: To protect the client from self-injury, the nurse uses padded side rails. The nurse should avoid restraints, because straining against them can increase ICP or cause other injury. Narcotics used to control restless clients should be avoided because these medications can depress respiration, constrict the pupils, and alter the client's responsiveness. Visitors should be limited if the client is agitated.
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 manifestations of neurogenic shock. In addition to monitoring the client closely, what would be the nurse's most appropriate action? -Place the client in the Trendelenburg position. -Prepare to transfuse packed red blood cells. -Prepare for interventions to increase the client's BP. -Prepare an ice bath to lower core body temperature.
Prepare for interventions to increase the client's BP. Explanation: Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock. Transfusion, repositioning, and ice baths are not indicated interventions.
A patient is diagnosed with a spinal cord tumor and has had a course of radiation and chemotherapy. Two months after the completion of the radiation, the patient complains of severe pain in the back. What is pain an indicator of in a patient with a spinal cord tumor? -The development of a skin ulcer from the radiation -Spinal metastasis -Lumbar sacral strain -Hematoma formation
Spinal metastasis Explanation: Pain is the hallmark of spinal metastasis. Patients with sensory root involvement may suffer excruciating pain, which requires effective pain management.
A client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of their urinary catheter, stating that they want to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention? Urinary function is permanently lost following an SCI. Overuse of urinary catheters can exacerbate nerve damage. Urinary catheters should not remain in place for more than 7 days. Urinary retention can have serious consequences in clients with SCIs.
Urinary retention can have serious consequences in clients with SCIs. Explanation: Bladder distention, a major cause of autonomic dysreflexia, can also cause trauma. For this reason, removal of a urinary catheter must be considered with caution. Extended use of urinary catheterization is often necessary following SCI. The effect of a spinal cord lesion on urinary function depends on the level of the injury. Catheter use does not cause nerve damage, although it is a major risk factor for UTIs.
