Chapter 45: PrepU - Nursing Management: Patients With Neurologic Trauma
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? 1- acute 2- chronic 3- subacute 4- intracerebral
1
A patient admitted for the treatment of a nondepressed skull fracture has been leaking clear fluid from his nose, and glucose testing confirms that it is cerebrospinal fluid (CSF). This development necessitates what nursing action? 1- Elevating the head of the bed to 30 degrees 2- Performing gentle nasal suctioning at 20 to 30 mm Hg 3- Insertion of a nasogastric (NG) tube to low suction 4- Positioning the patient side-lying
1
The initial sign of increasing intracranial pressure (ICP) includes 1- decreased level of consciousness. 2- herniation. 3- vomiting. 4- headache.
1
The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? 1- Position the client in the supine position 2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg 3- Restrain the client, as indicated 4- Administer enemas, as needed
2
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? 1- Akathisia 2- Spasticity 3- Ataxia 4- Myoclonus
2
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? 1- Babinski sign 2- Kernig's sign 3- Battle's sign 4- Brudzinski's sign
3
The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? 1- Cardiogenic shock 2- Tetraplegia 3- Spinal shock 4- Paraplegia
3
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? 1- Hypophysectomy 2- Application of Halo traction 3- Burr holes 4- Insertion of Crutchfield tongs
3
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 1- reports a headache. 2- reports generalized weakness. 3- sleeps for short periods of time. 4- vomits.
4
A client with a traumatic brain injury has developed increased intracranial pressure resulting in dibetes insipidus. While assessing the client, the nurse expects which of the following findings? 1- Excessive urine output and decreased urine osmolality 2- Oliguria and decreased urine osmolality 3- Oliguria and serum hyperosmolarity 4- Excessive urine output and serum hypo-osmolarity
1
When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? 1- Decerebrate 2- Normal 3- Flaccid 4- Decorticate
1
Which Glasgow Coma Scale score is indicative of a severe head injury? 1- 7 2- 9 3- 11 4- 13
1
Which are characteristics of autonomic dysreflexia? 1- severe hypertension, slow heart rate, pounding headache, sweating 2- severe hypotension, tachycardia, nausea, flushed skin 3- severe hypertension, tachycardia, blurred vision, dry skin 4- severe hypotension, slow heart rate, anxiety, dry skin
1
While snowboarding, a 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? 1- concussion 2- laceration 3- contusion 4- skull fracture
1
At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. 1- Bradycardia 2- Hypertension 3- Bradypnea 4- Hypotension 5- Tachycardia
1,2,3
Cerebrospinal fluid (CSF) studies would indicate which of the following in a patient suspected of having meningitis? Select all that apply. 1- Decreased glucose 2- Increased protein 3- Increased white blood cells 4- Decreased protein 5- Increased glucose
1,2,3
A client with a traumatic brain injury has developed increased intracranial pressure resulting in diabetes insipidus. The expected treatment would consist of which of the following? 1- Fluid restriction 2- Vasopressin therapy 3- Hypertonic saline solution 4- Diet containing extra sodium
2
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. What medication does the nurse know will be given to prevent further spinal cord damage? 1- Furosemide (Lasix) 2- Methylprednisolone (Solu-Medrol) 3- Cyclobenzaprine (Flexeril) 4- Hydralazine hydrochloride (Apresoline)
2
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? 1- Placing the patient on a fluid restriction 2- Applying thigh-high elastic stockings 3- Administering an antifibrinolytic agent 4- Assisting the patient with passive range of motion exercises
2
A client with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone (SIADH). Which is an important nursing action for this client? 1- Maintaining adequate hydration 2- Administering prescribed antipyretics 3- Restricting fluid intake and hydration 4- Hyperoxygenation before and after tracheal suctioning
3
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? 1- An epidural hematoma 2- An extradural hematoma 3- An intracerebral hematoma 4- A subdural hematoma
3
An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to 1- control fever. 2- control shivering. 3- dehydrate the brain and reduce cerebral edema. 4- reduce cellular metabolic demand.
3
A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered
4
A client with a spinal cord injury has full head and neck control when the injury is at which level? 1- C1 2- C2 to C3 3- C4 4- C5
4
A nurse is assisting with the clinical examination for determination of brain death for a client, related to potential organ donation. All 50 states in the United States recognize uniform criteria for brain death. The nurse is aware that the three cardinal signs of brain death on clinical examination are all of the following except: 1- Coma 2- Absence of brain stem reflexes 3- Apnea 4- Glasgow Coma Scale of 6
4
A nurse observes an abnormal posture response in an unconscious patient. She documents "extension and outward rotation of the upper extremities and plantar flexion of the feet." She is aware that this posture is a clinical indicator of which of the following? 1- A brain lesion that causes a spontaneous response that changes with electrical activity in the brain 2- Cerebral hemisphere pathology that will cause alterations in flaccidity and contraction of motor responses 3- Decorticate positioning indicating damage to the upper midbrain 4- Decerebrate positioning implying severe dysfunction and brain pathology
4
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? 1- Simple 2- Comminuted 3- Depressed 4- Basilar
4
Which condition occurs when blood collects between the dura mater and arachnoid membrane? 1- Intracerebral hemorrhage 2- Epidural hematoma 3- Extradural hematoma 4- Subdural hematoma
4
A patient is admitted to the emergency room with a skull fracture. The nurse notes a blood stain, surrounded by a yellowish ring, on the linens on the stretcher. The patient's respiratory system was stabilized at the site of the accident. Which of the following nursing interventions describes the immediate nursing action that needs to be taken? 1- Tell the patient not to blow his nose. 2- Put a note about avoiding the use of a suction catheter at the head of the bed. 3- Test the fluid leaking from the patient's ears for glucose. 4- Elevate the head of the bed 30 degrees.
4
Which are risk factors for spinal cord injury (SCI)? Select all that apply. 1- Young age 2- Female gender 3- Alcohol use 4- Drug abuse 5- Caucasian ethnicity
1,3,4
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? 1- Examine the skin for any area of pressure or irritation. 2- Examine the rectum for a fecal mass. 3- Empty the bladder immediately. 4- Raise the head of the bed and place the patient in a sitting position.
4
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? 1- Signs of infection 2- Intake and output 3- Nutritional status 4- Body temperature
4
A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? 1- Decerebrate posturing and loss of corneal reflex 2- Loss of gag reflex and mental confusion 3- Complaints of headache and lack of pupillary response 4- Mental confusion and pupillary changes
1
Episodes of orthostatic hypotension occur in the first 2 weeks after a spinal cord injury. Compare the two blood pressure measurement for each answer. The blood pressure reading obtained when the patient was sitting, is in the left column for comparison. Which of the following shows the blood pressure measurement indicative of orthostatic hypotension? 1- 140/110 130/110 2- 140/100 120/90 3- 130/90 125/85 4- 130/80 120/80
2
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? 1- Sciatic nerve pain 2- Herniation 3- Paresthesia 4- Paralysis
3
During a Tensilon test to determine if a patient has myasthenia gravis, the patient complains of cramping and becomes diaphoretic. Vital signs are BP 130/78, HR 42, and respiration 18. What intervention should the nurse prepare to do? 1- Place the patient in the supine position. 2- Administer diphenhydramine (Benadryl) for the allergic reaction. 3- Administer atropine to control the side effects of edrophonium. 4- Call the rapid response team because the patient is preparing to arrest.
3