Chapter 39: Caring for Clients with Head and Spinal Cord Trauma Prep- U Med Surg
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."
A client with quadriplegia is in spinal shock. What finding should the nurse expect?
Absence of reflexes along with flaccid extremities
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?
Applying thigh-high elastic stockings
Which instructions should the nurse give a client who has been given a skeletal muscle relaxant for a herniated intervertebral disk?
Avoid driving or operating equipment.
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
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?
Battle's sign
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
At which of the following spinal cord injury levels does the patient have full head and neck control?
C5
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery?
Epidural
A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?
Epidural hematoma
A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device?
It allows for stabilization of the cervical spine along with early ambulation
A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of:
Leakage of cerebrospinal fluid (CSF)
A client 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 is brought to the ED by family after falling off the roof. The care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention?
Making openings in the skull
Following a spinal cord injury, a client is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
Notify the neurosurgeon of the occurrence.
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?
Pad the side rails of the client's bed.
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?
Perform passive ROM exercises as prescribed.
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 injury Risk for powerlessness Risk for knowledge deficit
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
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
T6
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's speech is slightly slurred.
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
An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (ICP) for which of the following actions?
To dehydrate the brain and reduce cerebral edema
A male client who is being treated in the hospital for a spinal cord injury (SCI) is advocating for the removal of the 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 catheter use often leads to urinary tract infections (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?
Watchful waiting and close monitoring
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury?
Widened pulse pressure
Which of the following findings in the patient who has sustained a head injury indicate increasing intracranial pressure (ICP)?
Widened pulse pressure
Which of the following is a sign of increasing ICP?
Widening 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
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.
chronic subdural hematoma computed tomography (CT) imaging of the brain
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:
chronic traumatic encephalopathy.
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:
chronic traumatic encephalopathy.
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.
What are the immediate complications of spinal cord injury? Select all that apply.
respiratory arrest spinal shock
A public health nurse offers public education in high school classes on personal responsibility in preventing head injuries as a way of life. While avoiding alcohol and drugs not only complies with existing law for minors, it also is an available intervention to prevent head injuries. What other measures are available to prevent head injuries?
using seatbelts
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.
The ED nurse is receiving a client handoff report at the beginning of the nursing shift. The departing nurse notes that the client with a head injury shows Battle sign. The incoming nurse expects which to observe clinical manifestation?
An area of bruising over the mastoid bone
The nurse reviews the physician's emergency department progress notes for the client who sustained a head injury and sees that the physician observed the Battle sign. The nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
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
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
The nurse has implemented interventions aimed at facilitating family coping in the care of a client with a traumatic brain injury. How can the nurse best facilitate family coping?
Assist the family in setting appropriate short-term goals.
A client with a T4 level spinal cord injury (SCI) is complaining of a severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp. Which of the following does the nurse suspect?
Autonomic dysreflexia
A halo sign is indicative of which of the following complication of brain injury?
Cerebrospinal fluid (CSF) leak
The nurse is planning the care of a client with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity." How can the nurse best address this risk?
Change the client's position frequently.
A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?
Check the client's indwelling urinary catheter for kinks to ensure patency.
The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?
Ecchymosis over the mastoid
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.
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
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 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
The nurse caring for a client with a spinal cord injury notes that the client is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?
Increase the frequency of ROM exercises.
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?
MRI
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?
Prepare for interventions to increase the client's BP.
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
Spinal shock
Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
Subdural
Which condition occurs when blood collects between the dura mater and arachnoid membrane?
Subdural hematoma
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."
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.
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:
Increased intracranial pressure (ICP)
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
concussion
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
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?
Ineffective airway clearance related to brain injury
A client is admitted with a cervical spine injury sustained during a diving accident. When planning this client's care, the nurse should assign highest priority to which nursing diagnosis?
Ineffective breathing pattern
A client is admitted to the neurologic intensive care unit (ICU) with a suspected diffuse axonal injury. Which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure?
Magnetic resonance imaging (MRI)
An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?
Maintain the patency of the patient's airway.
A client with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the client's risk for orthostatic hypotension?
Monitor the client's BP before and during position changes.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old client who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what event?
Motor vehicle accidents
An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
Motor vehicle accidents
The nurse is discussing spinal cord injury (SCI) at a health fair at a local high school. The nurse relays that the most common cause of SCI is
Motor vehicle crashes
Which is the most common cause of spinal cord injury (SCI)?
Motor vehicle crashes
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?
Personality changes
The earliest sign of serious impairment of brain circulation related to increased ICP is:
A change in consciousness.
A client in the emergency department has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the client has which type of skull fracture?
Basilar
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
Basilar
A client is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this client, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this client?
Ineffective breathing patterns related to weakness of the intercostal muscles
A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound?
Irrigates the wound to remove debris
The nurse 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
