Chapter 39, Caring for Clients With Head and Spinal Cord Trauma.rtf

You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply.

Bladder distention Poikilothermia No perspiration below the level of the injury

The nurse is caring for a client with a spinal cord injury leaving paralysis. When planning care related to the musculoskeletal system, which considerations are important? Select all that apply.

Bone demineralization Contractures Spasticity Limited range of motion

A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated?

Cell transplantation therapy allows the replacement of nerve cells that are damaged.

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

Conception is not impaired; the birth process is determined with the physician.

The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of accident. The nurse provides all details to the next shift and is most accurate to report which type of injury?

Contrecoup injury

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

Edema to the head with bruising of the mastoid process

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

Keep the client hydrated.

The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply.

Monitor vital signs Intake and output Coughing and deep breathing Neurovascular assessment of the lower extremity Dressing assessment

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.

A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize?

Nucleus pulposus

The nurse is caring for a client who was discovering 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 has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?

The client's medications include warfarin (Coumadin).

The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?

The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location differentiates the two disorders?

The first thoracic vertebrae

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 mother brings her 6-year-old to the emergency department (ED) after the child fell off the bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

"A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain."

The nurse is caring for a client with a herniation of C4. What item does the nurse anticipate to use if conservative therapy is used?

A cervical collar

The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, "What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain." The nurse is most correct to turn the teaching to which surgical procedure?

A spinal fusion

The nurse is orienting a new nurse to the neurologic unit. When instructing on the typical care provided to a client with head injuries, which type of medications are frequently administered? Select all that apply.

Anticonvulsants Analgesics Antibiotics

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

Body temperature

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

Epidural hematoma

You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on the medication?

Expect sensory changes, such as hearing a clicking sound, around the bone flap.

The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid?

Halo sign

The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved?

Herniation occurs through the foramen magnum.

The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location?

Iliac crest

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

Neurologic examination

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

The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?

Pulse and blood pressure

The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove anti-embolism stockings. What would the nurse do to accurately complete this intervention?

Remove the anti-embolism stockings briefly every 8 hours.

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

Subdural

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

Sympathetic nervous system

The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear.

The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care?

The client who played soccer in college

The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?

The client with a basilar fracture