Chapter 68
A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
Absence of reflexes along with flaccid extremities
Paramedics have brought an intubated patient to the RD following a head injury due to acceleration- deceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?
Administer benzodiazepines on a PRN basis
The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death? Select all that apply.
Apnea Coma Absence of brain stem reflexes
A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
Applying thigh-high elastic stockings
The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
Assist the family in setting appropriate short-term goals.
The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
Baclofen (Lioresal)
A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
Bradycardia and hypertension
The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
Bruising over the mastoid
The nurse is planning the care of a patient 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 patients position frequently.
A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
Check the patients indwelling urinary catheter for kinks to ensure patency.
The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement?
Cluster overnight nursing activities to minimize disturbances.
The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
Ensure that the player is not moved.
Splints have been ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
Every 2 hours
The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
Hyperthermia
The nurse caring for a patient with a spinal cord injury notes that the patient 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 patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?
Initiating (ROM) exercises as soon as possible after the injury
A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?
Level of consciousness
A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?
MRI
A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?
Monitor the patients BP before and during position changes.
An ED nurse has just received a call from EMS that they are transporting a 17-year-old man 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
Following a spinal cord injury a patient 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 patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. What are the potential complications that should be monitored for in this patient? Select all that apply.
Orthostatic hypotension Autonomic dysreflexia DVT
The nurse recognizes that a patient 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 ordered.
The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?
Prepare for interventions to increase the patients BP.
The ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?
Preserving brain homeostasis
A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?
Risk for injury
A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient 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
A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?
The patient will require full assistance for all aspects of elimination.
A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care teams decision regarding this intervention?
Urinary retention can have serious consequences in patients with SCIs.
A patient 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
The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.
Young age Male gender Alcohol or drug use
A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?
As soon as the initial assessment is made
A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?
Emergency craniotomy
A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
Grade 3 concussion with temporal lobe involvement
An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?
Hematoma
A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
Ineffective breathing patterns related to weakness of the intercostal muscles
A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?
Pad the side rails of the patients bed.
A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?
The patients urinary catheter became occluded.
The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency. What would be the nurses best answer?
The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
To avoid impeding venous outflow
