CoursePoint - Chapter 63: Management of Patients with Neurologic Trauma
A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose?
0.5 mL
A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose?
1.6 mL
The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?
80 mL/hr
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? A. Symptoms will evolve over a period of 1 week B. The crash cart with defibrillator is kept nearby C. Monitoring is needed as rapid neurologic deterioration may occur D. Bleeding continues into the intracerebral area
C. Monitoring is needed as rapid neurologic deterioration may occur The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
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? A. Administers acetaminophen (Tylenol) for headache B. Shaves the hair around the wound C. Administers an oral analgesic for pain D. Irrigates the wound to remove debris
D. Irrigates the wound to remove debris Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.
Which is the most common cause of spinal cord injury (SCI)? A. Sports-related injuries B. Motor vehicle crashes C. Acts of violence D. Falls
B. Motor vehicle crashes The most common cause of SCI is motor vehicles crashes, which account for 35% of the injuries. Falls, sports-related injuries, and acts of violence are also potential causes of SCI, but are not most common.
Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply. A. Infection B. Hyperthermia C. Ischemia D. Cerebral edema E. Seizures
A, B, C, D, E Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia.
The nurse is providing information about spinal cord injury (SCI) prevention to a community group of young adults. The nurse mentions that all of the following are predominant risk factors for SCI except? A. Being an athlete B. Alcohol/drug use C. Male gender D. Young age
A. Being an athlete The predominant risk factors for SCI include young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use.
Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)? A. Change in level of consciousness (LOC) B. Restlessness C. Pupil changes D. Seizures
A. Change in level of consciousness (LOC) The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.
Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. A. Verbal response B. Intelligence C. Muscle strength D. Motor response E. Eye opening
A, D, E LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15. Intelligence and muscle strength are not measured in the GCS.
Which Glasgow Coma Scale score is indicative of a severe head injury? A. 7 B. 9 C. 11 D. 13
A. 7 A score between 3 and 8 is generally accepted as indicating a severe head injury.
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? A. Ecchymosis over the mastoid B. Drainage of cerebrospinal fluid from the nose C. Bruising under the eyes D. Drainage of cerebrospinal fluid from the ears
A. Ecchymosis over the mastoid With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.
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. A. Hypotension B. Hypertension C. Bradycardia D. Bradypnea E. Tachycardia
B, C, D The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.
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? A. Escape of cerebrospinal fluid from the client's ear B. An area of bruising over the mastoid bone C. A bloodstain surrounded by a yellowish stain on the head dressing D. Escape of cerebrospinal fluid from the client's nose
B. An area of bruising over the mastoid bone Battle sign may indicate a skull fracture. A bloodstain surrounded by a yellowish stain on the head dressing is referred to as a halo sign and is highly suggestive of a cerebrospinal fluid (CSF) leak. Escape of CSF from the client's ear is termed otorrhea. Escape of CSF from the client's nose is termed rhinorrhea.
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? A. Numbness and tingling B. Pulse and blood pressure C. Pain level D. Respiratory pattern
B. Pulse and blood pressure Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
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? A. Examine the skin for any area of pressure or irritation B. Raise the head of the bed and place the patient in a sitting position C. Empty the bladder immediately D. Examine the rectum for a fecal mass
B. Raise the head of the bed and place the patient in a sitting position The head of the bed is raised and the patient is placed immediately in a sitting position to lower blood pressure. Assessment of body systems is done after the emergency has been addressed.
Which are characteristics of autonomic dysreflexia? A. severe hypotension, tachycardia, nausea, flushed skin B. severe hypertension, slow heart rate, pounding headache, sweating C. severe hypertension, tachycardia, blurred vision, dry skin D. severe hypotension, slow heart rate, anxiety, dry skin
B. severe hypertension, slow heart rate, pounding headache, sweating Autonomic dysreflexia is an exaggerated sympathetic nervous system response. Hypertension, tachycardia, bradycardia, and flushed skin would occur.
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? A. Normal B. Flaccid C. Decerebrate D. Decorticate
C. Decerebrate Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
A client with weakness and tingling in both legs is admitted to the medical-surgical unit with a tentative diagnosis of Guillain-Barré syndrome. On admission, which assessment is most important for this client? A. Evaluation of pain and discomfort B. Evaluation of nutritional status and metabolic state C. Lung auscultation and measurement of vital capacity and tidal volume D. Evaluation for signs and symptoms of increased intracranial pressure (ICP)
C. Lung auscultation and measurement of vital capacity and tidal volume In Guillain-Barré syndrome, polyneuritis commonly causes weakness and paralysis, which may ascend to the trunk and involve the respiratory muscles. Lung auscultation and measurement of vital capacity, tidal volume, and negative inspiratory force are crucial in detecting and preventing respiratory failure — the most serious complication of polyneuritis. A peripheral nerve disorder, polyneuritis doesn't cause increased ICP. Although the nurse must evaluate the client for pain and discomfort and must assess the nutritional status and metabolic state, these aren't priorities.
The most important nursing priority of treatment for a patient with an altered LOC is to: A. Stabilize the blood pressure and heart rate to ensure adequate perfusion of the brain B. Prevent dehydration and renal failure by inserting an IV line for fluids and medications C. Maintain a clear airway to ensure adequate ventilation D. Position the patient to prevent injury and ensure dignity
C. Maintain a clear airway to ensure adequate ventilation The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. The patient may be orally or nasally intubated (unless basilar skull fracture or facial trauma is suspected), or a tracheostomy may be performed. Until the ability of the patient to breathe on his or her own is determined, a mechanical ventilator is used to maintain adequate oxygenation and ventilation.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? A. Assessing laboratory test results as ordered B. Placing the client in Trendelenburg's position C. Monitoring the patency of an indwelling urinary catheter D. Administering zolpidem tartrate (Ambien)
C. Monitoring the patency of an indwelling urinary catheter A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
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? A. Sciatic nerve pain B. Herniation C. Paresthesia D. Paralysis
C. Paresthesia When a client reports numbness and tingling in an area, the client is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parentheses. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis.
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: A. Brain death B. Mild TBI C. Severe TBI D. Moderate TBI
C. Severe TBI A score of 13 to 15 is classified as mild TBI, 9 to 12 is moderate TBI, and 3 to 8 is severe TBI. A score of 3 indicates severe impairment of neurologic function, deep coma, brain death, or pharmacologic inhibition of the neurologic response; a score of 8 or less typically indicates an unconscious patient; a score of 15 indicates a fully alert and oriented patient.
Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? A. Akathisia B. Myoclonus C. Ataxia D. Spasticity
D. Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.
A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of diabetes insipidus. Which of the following would be an appropriate nursing intervention to monitor for early signs of diabetes insipidus? A. Reposition the client frequently B. Assess for pupillary response frequently C. Assess vital signs frequently D. Take daily weights
D. Take daily weights A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of diabetes insipidus. A weight loss will alert the nurse to possible fluid imbalance early in the process.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care? A. client reports no discomfort B. client's skin remains clean, dry, and intact C. client regains bowel elimination capacity D. client maintains mechanical ventilation with minimal mucus accumulation
D. client maintains mechanical ventilation with minimal mucus accumulation A client with a lumbar spinal injury would not require mechanical ventilation.
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? A. Basilar B. Depressed C. Comminuted D. Simple
A. Basilar Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
The nurse working on a neurological unit is mentoring a nursing student. The student asks about a client who has sustained a primary and secondary brain injury. The nurse correctly tells the student which of the following, related to the primary injury? A. It results from initial damage to the brain from the traumatic event B. It refers to the permanent deficits seen after the rehabilitation process C. It refers to the difficulties suffered by the client and family related to the changes in the client D. It results from inadequate delivery of nutrients and oxygen to the cells
A. It results from initial damage to the brain from the traumatic event The primary injury results from the initial damage from the traumatic event. The secondary injury results from inadequate delivery of nutrients and oxygen to the cells, usually due to cerebral edema and increased intracranial pressure.
The earliest sign of serious impairment of brain circulation related to increased ICP is: A. A bounding pulse B. A change in consciousness C. Hypertension D. Bradycardia
B. A change in consciousness The earliest sign of increasing ICP is a change in the LOC. Any changes in LOC should be reported immediately.
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. The nurse anticipates that the client has developed [A. acute subdural hematoma, B. chronic subdural hematoma, C. stroke] and that [A. computed tomography (CT) imaging of the brain, B. electrocardiogram (ECG), C. coagulation profile] will be ordered.
B, A This client has had a prior head trauma with a negative imaging scan. Prior head trauma can lead to the development of a chronic subdural hematoma, which presents with symptoms such as severe headache, mental deterioration, focal neurologic changes, personality changes, and/or symptoms that the client is having a stroke. There is no indication that the client had follow-up imaging based on the prior head trauma, which should be included in protocol management of head injuries. Prior head trauma can lead to the development of a chronic subdural hematoma. Based on the clinical presentation of a severe headache, this is the most likely clinical diagnosis. Based on the clinical presentation, follow-up imaging is indicated to confirm the presence of a chronic subdural hematoma, which can occur following a recent head trauma. Because the head trauma occurred a few months ago, an acute finding would have presented earlier, at the time of injury. The differential diagnosis of chronic subdural hematoma includes a stroke but there is insufficient clinical evidence to support this finding. An electrocardiogram (ECG) is not indicated at this time because there is no provided clinical evidence of any cardiac abnormalities. Coagulation studies are not indicated at this time because the priority is to obtain an imaging study.
Which condition occurs when blood collects between the dura mater and arachnoid membrane? A. Extradural hematoma B. Subdural hematoma C. Intracerebral hemorrhage D. Epidural hematoma
B. Subdural hematoma A subdural hematoma is a collection of blood between the dura mater and the brain, a space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.
Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? A. Increased pulse B. Widened pulse pressure C. Decreased body temperature D. Increased respirations
B. Widened pulse pressure Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure, and widening pulse pressure (Cushing reflex). As brain compression increases, respirations decrease or become erratic, blood pressure may decrease, and the pulse slows further. This is an ominous development, as is a rapid fluctuation of vital signs. Temperature is maintained at less than 38°C (100.4°F). Tachycardia and arterial hypotension may indicate that bleeding is occurring elsewhere in the body.
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? A. laceration B. contusion C. concussion D. skull fracture
C. concussion A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.
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 A. sleeps for short periods of time B. reports a headache C. vomits D. reports generalized weakness
C. vomits Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.
While stopped at a stop sign, a patient's car was struck from behind by another vehicle. The patient sustained a cerebral contusion and was admitted to the hospital. During what time period after the injury will the effects of injury peak? A. 12 to 24 hours B. 48 to 72 hours C. 6 to 8 hours D. 18 to 36 hours
D. 18 to 36 hours Contusions are characterized by loss of consciousness associated with stupor and confusion. Other characteristics can include tissue alteration and neurologic deficit without hematoma formation, alteration in consciousness without localizing signs, and hemorrhage into the tissue that varies in size and is surrounded by edema. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.
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? A. Disturbed sensory perception (tactile) B. Impaired physical mobility C. Dressing or grooming self-care deficit D. Ineffective breathing pattern
D. Ineffective breathing pattern Because a cervical injuspinery can cause respiratory distress, the nurse should take immediate action to maintain a patent airway and provide adequate oxygenation. Impaired physical mobility, Disturbed sensory perception (tactile), and Dressing or grooming self-care deficit may be appropriate for a client with a spinal cord injury — particularly during the course of recovery — but they don't take precedence over a diagnosis of Ineffective breathing pattern.
The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? A. Out of bed to the chair three times a day B. Urine testing for acetone C. Serum sodium concentration testing D. Insertion of a nasogastric (NG) tube
D. Insertion of a nasogastric (NG) tube Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.
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? A. Watch closely for signs of urinary tract infection B. Keep accurate intake and output C. Avoid range of motion exercises for the client because of spasms D. Maintain a diet for the client that is high in protein, vitamins, and calories
D. Maintain a diet for the client that is high in protein, vitamins, and calories To maintain healthy skin, the following interventions are necessary: regularly relieve pressure, protect from injury, keep clean and dry, avoid wrinkles in the bed, and maintain a diet high in protein, vitamins, and calories to ensure minimal wasting of muscles and healthy skin.
A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply. A. Weakness on one side of the body B. Sleeps for short periods of time C. Slurred speech D. Headache E. Vomiting
A, C, E Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately.
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? A. "I can apply powder under the liner to help with sweating." B. "If a pin becomes detached, I'll notify the surgeon." C. "I will change the vest liner periodically." D. "I'll check under the liner for blisters and redness."
A. "I can apply powder under the liner to help with sweating." Powder is not used inside the vest because it may contribute to the development of pressure ulcers. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.
A client with paraplegia asks why exercises are done to the lower extremities every day. Which response will the nurse make? A. "They help prevent the development of contractures." B. "They aid in restoring your skeletal integrity." C. "They help stabilize total body functioning." D. "They prepare you to function in the absence of your leg function."
A. "They help prevent the development of contractures." Clients are at high risk for the development of contractures as a result of disuse syndrome due to the musculoskeletal system changes brought about by the loss of motor and sensory functions below the level of injury. Range-of-motion exercises must be provided at least four times a day, and care is taken to stretch the Achilles tendon with exercises to prevent footdrop. Range-of-motion exercises are not done to stabilize total body functioning or restore skeletal integrity. Exercise programs are used to prepare to function in the absence of leg function.
A client with quadriplegia is in spinal shock. What finding should the nurse expect? A. Absence of reflexes along with flaccid extremities B. Positive Babinski's reflex along with spastic extremities C. Hyperreflexia along with spastic extremities D. Spasticity of all four extremities
A. Absence of reflexes along with flaccid extremities During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the client will demonstrate positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? A. Apply elastic stockings to lower extremities B. Assist the patient with frequent ambulation C. Take care not to jar the bed or cause unnecessary activity D. Elevate patient's head or follow the physician's directive for body position
A. Apply elastic stockings to lower extremities To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? A. Look for signs of increased intracranial pressure B. Look for a halo sign C. Have the client avoid physical exertion D. Emphasize complete bed rest
A. Look for signs of increased intracranial pressure The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.
A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? A. Place in a seated position B. Palpate the bladder for distention C. Asses the skin for areas of pressure D. Examine the rectum for a fecal mass
A. Place in a seated position Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.
Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury? A. Placing a blanket over the client B. Diarrhea C. Placing the client in a sitting position D. Voiding
A. Placing a blanket over the client An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.
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? A. Temperature increase from 98.0°F to 99.6°F B. Urinary output increase from 40 to 55 mL/hr C. Pulse oximetry decrease from 99% to 97% room air D. Heart rate decrease from 100 to 90 bpm
A. Temperature increase from 98.0°F to 99.6°F Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.
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 should the nurse explain differentiates the two disorders? A. The first thoracic vertebrae B. The first lumbar vertebrae C. The second cervical vertebrae The seventh thoracic vertebrae
A. The first thoracic vertebrae Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. Trendelenburg's B. 30-degree head elevation C. Flat D. Side-lying
B. 30-degree head elevation For clients with increased intracranial pressure (ICP), the head of the bed should be elevated to 30 degrees to promote venous outflow. Trendelenburg's position is contraindicated because it can raise ICP. Flat or neutral positioning is indicated when elevating the head of the bed would increase the risk of neck injury or airway obstruction. A side-lying position isn't specifically a therapeutic treatment for increased ICP.
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? A. Thrombophlebitis B. Autonomic dysreflexia C. Orthostatic hypotension D. Spinal shock
B. Autonomic dysreflexia Autonomic dysreflexia occurs only after spinal shock has resolved. It is characterized by a severe, pounding headache, marked hypertension, diaphoresis, nausea, nasal congestion, and bradycardia. It occurs only with SCIs above T6 and is a hypertensive emergency. It is not related to thrombophlebitis.
At which of the following spinal cord injury levels does the patient have full head and neck control? A. C3 B. C5 C. C4 D. C2
B. C5 At the level of C5, the patient should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the patient will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the patient will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.
A 24-year-old female rock climber is brought to the emergency department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? A. Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow B. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue C. Contusions are microscopic brain injuries D. Contusions are deep brain injuries
B. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury. Edema develops at the site of or in areas opposite to the injury. A skull fracture can accompany a contusion. Therefore the other options are incorrect.
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: A. Coma B. Glasgow Coma Scale of 6 C. Apnea D. Absence of brain stem reflexes
B. Glasgow Coma Scale of 6 The three cardinal signs of brain death on clinical examination are coma, absence of brain stem reflexes, and apnea. The Glasgow Coma Scale is a tool for determining the client's level of consciousness. A score of 3 indicates a deep coma, and a score of 15 is normal.
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? A. Computed tomography (CT) scan B. Neurologic examination C. Myelography D. Radiography
B. Neurologic examination A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.
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? A. Dressing or grooming self-care deficit B. Risk for injury C. Disturbed sensory perception (visual) D. Impaired verbal communication
B. Risk for injury Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury. Although Disturbed sensory perception (visual), Dressing or grooming self-care deficit, and Impaired verbal communication may all be appropriate, they're secondary because they don't immediately affect the client's health or safety.
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? A. Disturbed sensory perception (visual) related to neurologic trauma B. Risk for injury related to neurologic deficit C. Impaired verbal communication related to confusion D. Feeding self-care deficit related to neurologic trauma
B. Risk for injury related to neurologic deficit Because a cerebral contusion causes altered cognition, the nurse should identify Risk for injury related to neurologic deficit as the primary nursing diagnosis and focus on interventions that promote client safety and prevent further injury. Disturbed sensory perception (visual) related to neurologic trauma, Feeding self-care deficit related to neurologic trauma, and Impaired verbal communication related to confusion are pertinent but don't take precedence over client safety.
Which are risk factors for spinal cord injury (SCI)? Select all that apply. A. Female gender B. European American ethnicity C. Young age D. Drug abuse E. Alcohol use
C, D, E The predominant risk factors for SCI include young age, male gender, and alcohol and drug use. The frequency with which these risk factors are associated with SCI emphasizes the importance of primary prevention.
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? A. An epidural hematoma B. A subdural hematoma C. An intracerebral hematoma D. An extradural hematoma
C. An intracerebral hematoma Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.
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? A. Tetraplegia B. Areflexia C. Autonomic dysreflexia D. Paraplegia
C. Autonomic dysreflexia Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.
For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? A. To increase cerebral perfusion pressure B. So that the patient will not have a respiratory arrest C. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord D. To prevent secondary brain injury
C. Because hypoxemia can create or worsen a neurologic deficit of the spinal cord Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.
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? A. Insertion of Crutchfield tongs B. Application of Halo traction C. Burr holes D. Hypophysectomy
C. Burr holes An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull (burr holes) to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A. The client has serous drainage from the nose B. The client has ecchymosis in the periorbital region C. The client has cerebral spinal fluid (CSF) leaking from the ear D. The client has an elevated temperature
C. The client has cerebral spinal fluid (CSF) leaking from the ear Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? A. Extreme thirst B. Intake and output C. Nutritional status D. Body temperature
D. Body temperature It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor? A. Signs of infection B. Intake and output C. Nutritional status D. Body temperature
D. Body temperature It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.
A client with a spinal cord injury has full head and neck control when the injury is at which level? A. C1 B. C2 to C3 C. C4 D. C5
D. C5 At level C5, the client retains full head and neck control. At C1 the client has little or no sensation or control of the head and neck. At C2 to C3 the client feels head and neck sensation and has some neck control. At C4 the client has good head and neck sensation and motor control.
A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? A. Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction B. Ineffective cerebral tissue perfusion related to increased intracranial pressure C. Disturbed thought processes related to brain injury D. Ineffective airway clearance related to brain injury
D. Ineffective airway clearance related to brain injury Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.
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)? A. Administer enemas, as needed B. Position the client in the supine position C. Restrain the client, as indicated D. Maintain cerebral perfusion pressure from 50 to 70 mm Hg
D. Maintain cerebral perfusion pressure from 50 to 70 mm Hg The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.
