Exam 6

The nurse is caring for a client who had a hemorrhagic stroke. What assessment finding constitutes an early sign of deterioration? Generalized pain Alteration in level of consciousness (LOC) Tonic-clonic seizures Shortness of breath

Alteration in level of consciousness (LOC)

A nurse is caring for a female client following a motor vehicle accident resulting in paraplegia. The client is ready for discharge to home with her husband, who states, "I'm scared to carry her because I'm afraid I'll either hurt my back or drop her." What information will the nurse give the husband during discharge teaching? Ergonomic principles and body mechanics The importance of monitoring urinary elimination Signs and symptoms of chronic back pain that should be reported to the health care provider Nutritional changes for the client with paraplegia

Ergonomic principles and body mechanics

intracranial bleeding: Subdural hematoma

blood between the dura and brain 3 types: acute: symptoms develop over 24-48 hours. require immediate craniotomy and control of ICP subacute: symptoms develop over 48-2 weeks. require immediate craniotomy and control of ICP chronic: develops over weeks to months injury may be forgotten by then S&S fluctuate Evacuate clot

Chronic traumatic encephalopathy

form of dementia caused by repeated head trauma such as concussions

concussion interventions

report immediately if the patient has: changes in LOC difficulty in awakening lethargy dizziness confusion irritability anxiety difficulty with speaking difficulty with movement severe headache vomiting if pt is sent home, have family monitor for these things. pt should be aroused and assessed frequently for moderate and severe concussions

grade 1 (mild) concussion

symptoms last <15 minutes with no loss of consciousness

Types of brain injury

Concussion contusion closed brain injury open brain injury

secondary head injury

Damage evolves after the initial injury within hours or days. caused by cerebral edema, ischemia, or chemical changes associated with the trauma this injury occurs because of inadequate delivery of nutrients and oxygen to the cells

Which is a contraindication for the administration of tissue plasminogen activator (t-PA)? Systolic blood pressure less than or equal to 185 mm Hg Age 18 years or older Intracranial hemorrhage Ischemic stroke

Intracranial hemorrhage

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer? Glycerin Urea Mannitol Isosorbide

Mannitol

Family members of a client with traumatic brain injury are extremely distressed about their loved one. How can the nurse best assist the family to cope during this acute phase? Provide factual information and emotional support. Reassure them that progress will be made, but it takes time. Allow family members distance and space to deal with the changes to the client. Wait for the family members to approach with questions.

Provide factual information and emotional support.

A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client 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? Hypertensive emergency Hypovolemia Epidural hemorrhage Spinal shock

Spinal shock

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

Subdural

A client has developed diabetes insipidus after having increased ICP following head trauma. What nursing assessment best addresses this complication? Serial arterial blood gases (ABGs) Monitoring of the client's airway for patency Vigilant monitoring of fluid balance Continuous BP monitoring

Vigilant monitoring of fluid balance

Closed brain injury: blunt trauma

acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates damaging brain tissue

signs and symptoms of brain injury

altered LOC Abnormal pupils Neurologic changes in sensation, movement, and reflexes Changes in vital signs headache seizures

contusions

closed-head injuries that involve damage to the cerebral circulatory system more severe TBI with structural damage (possible surface hemorrhage) 2 types: coup and countrecoup

Contrecoup

injury to the brain at a point directly opposite the point of contact Longer period of unconsciousness with more symptoms of neurologic deficits and changes in vitals

grade 3 (severe) concussion

loss of consciousness

coup contusion

site of impact on frontal lobe. symptom and recovery depend on the amount of damage and associated cerebral edema

grade 2 (moderate) concussion

symptoms last >15 minutes with no loss of consciousness

diffuse axonal injury

type of brain injury characterized by shearing, stretching, or tearing of nerve fibers with subsequent axonal damage. Widespread damage seen with head trauma. Pt develops immediate coma One of the major causes of unconsciousness and persistent vegetative state after head trauma

When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? Flat Side-lying Trendelenburg's 30-degree head elevation

30-degree head elevation

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

A change in consciousness.

concussion

AKA closed head injury or mild TBI Caused by an acceleration/deceleration force, direct blow, or blast injury temporary loss of neurological function with no structural damage 3 grades mild, moderate, and severe

A client with a cerebral aneurysm exhibits signs and symptoms of an increase in intracranial pressure (ICP). What nursing intervention would be most appropriate for this client? Passive range-of-motion exercises to prevent contractures Supine positioning Absolute bed rest in a quiet, nonstimulating environment Early initiation of physical therapy

Absolute bed rest in a quiet, nonstimulating environment

Which of the following types of skull fractures may be evident by Battle's sign? Comminuted Simple Depressed Basilar

Basilar

A patient presents to the emergency room with complaints of having an "exploding headache" for the last 2 hours. The patient is immediately seen by a triage nurse who suspects the patient is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom? Small artery thrombosis Cardiogenic emboli Cerebral aneurysm Large artery thrombosis

Cerebral aneurysm

The nurse is planning the care of a client 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? Provide light massage at least daily. Provide a high-protein diet. Teach the client deep breathing and coughing exercises. Change the client's position frequently.

Change the client's position frequently.

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. Adoption is an option to complete your family but not put your life in jeopardy. Sterilization is best; it would be difficult to care for a baby in your condition. Birth via surrogate is best because your baby can be implanted in another woman.

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

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? Impaired physical mobility Disturbed sensory perception (tactile) Ineffective breathing pattern Dressing or grooming self-care deficit

Ineffective breathing pattern

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? It results from inadequate delivery of nutrients and oxygen to the cells. It refers to the difficulties suffered by the client and family related to the changes in the client. It results from initial damage to the brain from the traumatic event. It refers to the permanent deficits seen after the rehabilitation process.

It results from initial damage to the brain from the traumatic event.

A nurse is reviewing the trend of a client's scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the client's status? Level of consciousness Cognitive ability Sensory involvement Reflex activity

Level of consciousness

Which is the most common cause of spinal cord injury (SCI)? Falls Sports-related injuries Acts of violence Motor vehicle crashes

Motor vehicle crashes

A client is receiving baclofen for management of symptoms associated with multiple sclerosis. The nurse evaluates the effectiveness of this medication by assessing which of the following? Mood and affect Sleep pattern Appetite Muscle spasms

Muscle spasms

A nurse conducts the Romberg test on a client by asking the client to stand with the feet close together and the eyes closed. As a result of this posture, the client suddenly sways to one side and is about to fall when the nurse intervenes and saves the client from being injured. How should the nurse interpret the client's result? Positive Romberg test, indicating a problem with level of consciousness Negative Romberg test, indicating a problem with body mass Negative Romberg test, indicating a problem with vision Positive Romberg test, indicating a problem with equilibrium

Positive Romberg test, indicating a problem with equilibrium

A nurse is performing a neurologic assessment on a client with a stroke and cannot elicit a gag reflex. This deficit is related to cranial nerve (CN) X, the vagus nerve. What will the nurse consider a priority nursing diagnosis? Risk for falls Risk for impaired skin integrity Risk for aspiration Decreased intracranial adaptive capacity

Risk for aspiration

A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? Risk for injury related to neurologic deficit Feeding self-care deficit related to neurologic trauma Impaired verbal communication related to confusion Disturbed sensory perception (visual) related to neurologic trauma

Risk for injury related to neurologic deficit

Which oncologic emergency involves the failure in the negative feedback mechanism that normally regulates the release of antidiuretic hormone (ADH)? Disseminated intravascular coagulation (DIC) Tumor lysis syndrome Cardiac tamponade Syndrome of inappropriate antidiuretic hormone release (SIADH)

Syndrome of inappropriate antidiuretic hormone release (SIADH)

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client? They need a bath. They are getting spinal contractures. They have the beginning of a pressure sore. They are gaining weight.

They have the beginning of a pressure sore.

intracranial bleeding: intracerebral hemorrhage/hematoma

bleeding within the brain tissue may be traumatic or non-traumatic treatment: supportive care control of ICP administration of fluids, electrolytes, and antihypertensive meds craniotomy and craniectomy to remove clot and control hemorrhage but may not be possible

intracranial bleeding: epidural hematoma

blood between the skull and dura skull fracture can cause rupture or laceration of an artery may have brief loss of consciousness upon rupture with a return to lucid state. as the hematoma expands increase ICP will often suddenly reduce LOC This is an emergency: resp arrest within minutes the bodies compensation mechanisms fail. Increased ICP can cause herniation. the pt will need a craniotomy or burr holes monitor and support vital body functions including respiratory support.

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to control fever. control shivering. dehydrate the brain and reduce cerebral edema. reduce cellular metabolic demand.

dehydrate the brain and reduce cerebral edema.

clinical manifestations of brain injuries

depends on severity and location scalp wound: bleed heavily and are prone to infection skull fractures: have localized and persistent pain fractures at the base of the skull: bleeding from nose or ears, battles sign, CSF leak, prone to infection

Primary head injury

direct damage at time of injury; initial symptoms depend on site; motor cortex - contralateral weakness; frontal lobe - memory judgment behavioral change

A client is treated for increased intracranial pressure (ICP). It is important for the client to avoid hypothermia because hypothermia can cause death. shivering in hypothermia can increase ICP. hypothermia is indicative of severe meningitis. hypothermia is indicative of malaria.

shivering in hypothermia can increase ICP.

The nurse is assisting with a lumbar puncture and observes that when the physician obtains CSF, it is clear and colorless. What does this finding indicate? A subarachnoid hemorrhage Local trauma from the insertion of the needle An overwhelming infection A normal finding; the fluid will be sent for testing to determine other factors

A normal finding; the fluid will be sent for testing to determine other factors

A client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first? Declining level of consciousness (LOC) Irregular breathing pattern Involuntary posturing Pupillary asymmetry

Declining level of consciousness (LOC)

Open brain injury: object

object penetrates the brain of the trauma is so severe that the scalp and skul are opened