Chapter 68: Management of Patients With Neurologic Trauma

acute

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 - chronic - subacute - intracerebral

raccoon's eyes and Battle sign.

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. - nuchal rigidity and Kernig's sign. - motor loss in the legs that exceeds that in the arms. - pupillary changes.

Risk for injury

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? - Disturbed sensory perception (visual) - Dressing or grooming self-care deficit - Impaired verbal communication - Risk for injury

Look for signs of increased intracranial pressure

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? - Have the client avoid physical exertion - Emphasize complete bed rest - Look for signs of increased intracranial pressure - Look for a halo sign

Suction the airway

A client with spinal trauma tells the nurse she cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough? - Administer oxygen as prescribed. - Use mechanical ventilation. - Let the airway stay as it currently is. - Suction the airway.

Maintain a diet for the client that is high in protein, vitamins, and calories.

A client with tetraplegia cannot do his own skin care. The nurse is teaching the caregiver about the importance of maintaining skin integrity. Which of the following will the nurse most encourage the caregiver to do? - Maintain a diet for the client that is high in protein, vitamins, and calories. - Avoid range of motion exercises for the client because of spasms. - Keep accurate intake and output. - Watch closely for signs of urinary tract infection.

Glasgow Coma Scale of 6

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: - Coma - Absence of brain stem reflexes - Apnea - Glasgow Coma Scale of 6

Motor vehicle crashes

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 - Falls - Sports-related injuries - Motor vehicle crashes - Acts of violence

Edema to the head with bruising of the mastoid process

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate? - Edema to the head and a blackened eye - Edema to the head with a large scalp laceration - Edema to the head with fixed pupils - Edema to the head with bruising of the mastoid process

Record intake and output.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The health care team is concerned about the complication of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? - Assess frequent vital signs. - Reposition frequently. - Assess for pupillary response frequently. - Record intake and output.

Keep the client's neck in a neutral position (no flexing).

A client in the intensive care unit (ICU) has a traumatic brain injury. The nurse must implement interventions to help control intracranial pressure (ICP). Which of the following are appropriate interventions to help control ICP? - Keep the client's neck in a neutral position (no flexing). - Avoid sedation. - Cluster all procedures together. - Keep the head of the client's bed flat.

T6

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? - T6 - S2 - L4 - T10

A change in consciousness.

The earliest sign of serious impairment of brain circulation related to increased ICP is: - A bounding pulse. - Bradycardia. - Hypertension. - A change in consciousness.

Maintain a clear airway to ensure adequate ventilation.

The most important nursing priority of treatment for a patient with an altered LOC is to: - Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain. - Prevent dehydration and renal failure by inserting an IV line for fluids and medications. - Maintain a clear airway to ensure adequate ventilation. - Position the patient to prevent injury and ensure dignity.

Subdural hematoma

Which condition occurs when blood collects between the dura mater and arachnoid membrane? - Intracerebral hemorrhage - Epidural hematoma - Extradural hematoma - Subdural hematoma

Autonomic dysreflexia

You are a neurotrauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? - Tetraplegia - Areflexia - Autonomic dysreflexia - Paraplegia

Alteration in level of consciousness (LOC)

A client suffers a head injury. The nurse implements an assessment plan to monitor for potential subdural hematoma development. Which manifestation does the nurse anticipate seeing first? - Decreased heart rate - Bradycardia - Alteration in level of consciousness (LOC) - Slurred speech

"They help prevent the development of contractures."

A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? - "They help stabilize total body functioning." - "They help prevent the development of contractures." - "They aid in restoring your skeletal integrity." - "They prepare you to function in the absence of your leg function."

Spinal shock

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI? - Cardiogenic shock - Tetraplegia - Spinal shock - Paraplegia

Temperature increase from 98.0°F to 99.6°F

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 - Heart rate decrease from 100 to 90 bpm - Pulse oximetry decrease from 99% to 97% room air

Burr holes

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? - Hypophysectomy - Application of Halo traction - Burr holes - Insertion of Crutchfield tongs