head and spinal cord injury quiz questions
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? a. Elevating the head of the bed to 30 degrees b. Performing gentle nasal suctioning at 20 to 30 mm Hg c. Insertion of a nasogastric (NG) tube to low suction d. Positioning the patient side-lying
A
A patient 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
An 82-year-old client is admitted for observation after a fall. Due to the client's Ass inurgurse Knows that the clent is atinereased risk for what complicaion of a. Hematoma b. Skull fracture c. Embolus d. Stroke
A
The nurse enters the client's room and finds the client with an altered level of consciousness (LOC). Which is the nurse's priority concern? a. Airway clearance b. Risk of injury c. Deficient fluid volume d. Risk for impaired skin integrity
A
The nurse working on a neurological unit is mentoring a nursing student who asks about a client who has sustained primary and secondary brain injuries. The nurse correctly tells the student which of the following, related to the secondary injury? a. It results from inadequate delivery of nutrients and oxygen to the cells. b. It results from initial damage to the brain from the traumatic event. c. It refers to the permanent deficits seen after the rehabilitation process. d. It refers to the difficulties suffered by the client and family related to the changes in the client.
A
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. Bruising under the eyes c. Drainage of cerebrospinal fluid from the nose d. Drainage of cerebrospinal fluid from the ears
A
When caring for a client with a head injury, a nurse must stay alert for signs and symptoms of increased intracranial pressure (ICP). Which cardiovascular findings are late indicators of increased ICP? a. Rising blood pressure and bradycardia b. Hypotension and bradycardia c. Hypotension and tachycardia d. Hypertension and narrowing pulse pressure
A
Which of the following is not a maniestation of Cushings triad (Cushing refiex)? a. Tachycardia b. Widening pulse pressure c. Hypertension d. Irregular respiration
A
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? a. Herniation b. Autoregulation c. Cushing's response d. Monro-Kellie hypothesis
A
Which value indicates a normal intracranial pressure (ICP)? a. 5 mm Hg b. 17 mm Hg c. 20 mm Hg d. 27 mm Hg
A
A client 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 client? Select all that apply. a. Orthostatic hypotension b. Autonomic dysreflexia c. DVT d. Salt-wasting syndrome e. Increased ICP
A, B, C
Clinical manifestations of neurogenic shock include which of the following? Select all that apply. a. Venous pooling in the extremities b. Bradycardia c. Warm skin d. Tachycardia e. Profuse bilateral sweating
A, B, C
The nurse is caring for a client who sustained a head injury following a motor vehicle accident. The client is experiencing hyperthermia related to increased intracranial pressure. What interventions should the nurse include in the plan of care? Select all that apply. a. Administer acetaminophen as ordered for fever. b. Use rectal temperature probe when cooling blanket is in use. c. Treat shivering immediately. d. Administer warmed IV fluids. e. Keep the client dry and covered.
A, B, C
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. Cerebral edema b. Ischemia c. Infection d. Seizures e. Hyperthermia
A, B, C, D, E
A client has been diagnosed with a concussion and is preparing for discharge. The nurse educates the family members who will be caring for the client. What findings will alert the family to contact the physician or return to the ED? Select all that apply. a. Weakness on one side of the body b. Difficulty speaking c. Confusion d. Photophobia e. Seizure
A, B, C, E
A nurse is assessing a client who has sustained a traumatic brain injury. The client's Glasgow Coma Score (GCS) is 15. Which assessment would the nurse most likely document? Select all that apply. a. Eye opening response: spontaneous b. Best verbal response: confusion C. Best motor response: obeys command d. Eye opening response: to voice e. Best verbal response: oriented f. Best motor response: localizes pain
A, C, E
A client with a spinal cord injury has been rushed to the emergency department. What actions will the nurse take to prevent further injury? Select all that apply. a. Keeping the spine midline. b. Using a soft mattress to log roll the client. c. Administer high dose steroids. d. When possible, use at least 4 people to transfer the patient. Do not allow the patient to sit up
A, D, E
The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply. a. Hypertension b. Tachycardia c. Fever d. Diaphoresis e. Nasal congestion
A, D, E
24. A client who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following? a. Preparation for emergency craniotomy b. Watchful waiting and close monitoring c. Administration of inotropic drugs d. Fluid resuscitation
B
A client is brought to the emergency department with multiple fractures. Which sustered a closed ged ind he with ising inracraneal pressue the client has also a. Blood pressure 100/60 mm Hg b. Lethargy c. Nausea d. Periorbital edema
B
A client with a subdural hematoma is scheduled for craniotomy, but the surgery is delayed, and the client is to be maintained on complete bedrest until the surgery. What order, by the health care provider (HCP), should the nurse question? a. Implement seizure precautions. b. Heparin sodium 6000 units intravenous (IV). c. Nothing by mouth (NPO). d. Glycerin suppository per rectum (PR) q am.
B
A patient is demonstrating an altered LOC from a traumatic brain injury. Which assessment will the nurse use as a sensitive indicator of neurologic function? a. Cerebellar function b. Glasgow Coma Scale c. Cranial nerve function d. Mental status evaluation
B
A patient was admitted to a rehabilitation unit for treatment of a spinal cord injury. The admitting diagnosis is central cord syndrome. During an admissions physical, the nurse expects to find: a. loss of the sensation of pain and temperature on the side opposite the injury. b. loss of motor power and sensation in the upper extremities. c. preservation of a sense of touch below the level of the lesion. d. loss of motor power, pain, and temperature sensation below the level of the lesion.
B
The nurse is caring for a client who was involved in a motorcycle accident 7 days ago. Since admission the client has been unresponsive to painful stimuli. The client had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP of 14 with good waveforms, pulse 92, respirations per ventilator, temperature 102.7°F (rectal), urine output 320 mL in 4 hours, pupils pinpoint and briskly reactive, and hot, dry skin. Which is the a. Inspect the ICP monitor to ensure it is working properly. b. Administer acetaminophen per orders. c. Provide ventriculostomy care. d. Assess for signs and symptoms of infection.
B
Using the Glasgow Coma Scale, please determine the severity of brain injury: Eye opening to voice. Confused verbal response. Withdraws to pain. a. Mild; GCS 13-15 b. Moderate; GCS 9-12 c. Severe; GCS 3-7 d. more information is needed to determine GCS.
B
Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities? a. Decerebrate b. Decorticate c. Flaccid d. Normal
B
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. 6 to 8 hours b. 18 to 36 hours c. 12 to 24 hours d. 48 to 72 hours
B
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 reports which compiaions Selecta fat app i the client demonstrates a. Headache b. Slurred speech c. Sleeps for short periods of time d. Vomiting e. Weakness on one side of the body
B, D, E
The nurse is caring for a paraplegic client who presents with a chief complaint of a pounding headache. Upon assessment the nurse notes BP 185/130 mm Hg, HR 45 bpm, and perspiration around the head and neck. What actions are appropriate in the care of this client? Select all that apply. a. Place the client in a supine position. b. Assess for fecal impaction. c. Administer hydrocodone per protocol. d. Examine skin for signs of irritation. e. Inspect the indwelling urinary catheter for kinks.
B, D, E
(hathas tesulted in cerefral eema. When planing ths Cents care, the nurse would expect to administer what priority medication? a. Hydrochlorothiazide b. Furosemide c. Mannitol d. Spironlactone
C
A male patient is brought to the emergency department by his family after falling off his roof. A family member tells the nurse that when the patient fell he was "knocked out" but came to and "seemed to be okay." Now the patient is complaining of a severe headache and states that he is "not feeling well." The care team suspects an epidural hematoma. Based on the knowledge of the progression of this type of hematoma, the nurse prepares for which priority intervention? a. Insertion of an intracranial (IC) monitoring device b. Treatment with antihypertensives c. Emergency craniotomy d. Administration of anticoagulant therapy
C
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. Mild TBI. b. Moderate TBI. c. Severe TBI. d. Brain death.
C
A patient sustained a head trauma in a diving accident and has cerebral hemorrhage located within the brain. What type of hematoma is this classified as? a. An epidural hematoma b. An extradural hematoma c. An intracerebral hematoma d. A subdural hematoma
C
After a motor vehicle crash, a client is admitted to the medical-surgical unit with a cervical collar in place. The cervical spinal X-rays haven't been read, so the nurse doesn't know whether the client has a cervical spinal injury. Until such an injury is ruled out, the nurse should restrict this client to which position? a. Flat b. Supine, with the head of the bed elevated 30 degrees c. Flat, except for logrolling as needed d. A head elevation of 90 degrees to prevent cerebral swelling
C
The emergency department nurse is caring for a client who can move only his head and has flaccid paralysis of all extremities due to an acute compression fracture at C5. The injury occurred 12 hours ago. The client asks if the paralysis is permanent. What is the nurse's best therapeutic response? a. "Yes. The paralysis is probably permanent." b. "No. You should have a significant recovery of function in a few days." c. "It is too early to tell, when the spinal shock subsides, we will know more." d. "You should talk to your neurosurgeon about your paralysis."
C
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? a. Radiography b. Myelography c. Neurologic examination d. Computed tomography (CT) scan
C
Which action should the nurse perform when a client with a head injury begins to have clear drainage from the nose? a. Suction nose to evacuate cerebral spinal fluid. b. Place patient in supine position. c. Collect the drainage for testing. d. Instruct client to blow nose.
C
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? a. Subdural b. Intracerebral c. Epidural d. Diffuse axonal
C
The nurse is caring for a client who is 10 days post spinal cord injury and is experiencing frequent episodes of orthostatic hypotension. What nursing interventions will be implemented? Select all that apply. a. Administer Hydralazine as ordered. b. Restrict fluid intake. c. Apply elastic compression stockings. d. Monitor vital signs before and during position changes. e. Administer Vasopressors as ordered.
C, D, E
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. reports a headache. b. reports generalized weakness. c. sleeps for short periods of time. d. vomits.
D
A patient sustained a head injury and has been admitted to the neurosurgical intensive care unit (ICU). The patient began having seizures and was administered a sedative-hypnotic medication that is ultra-short acting and can be titrated to patient response. What medication will the nurse be monitoring during this time? a. Lorazepam (Ativan) b. Midazolam (Versed) c. Phenobarbital d. Propofol (Diprivan)
D
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms? a. Autonomic nervous system b. Central nervous system c. Peripheral nervous system d. Sympathetic nervous system
D
The rehabilitation nurse is admitting a client following a spinal cord injury. The nurse concludes that the client has developed Brown-Sequard (Lateral Cord) syndrome after identifying which assessment finding? a. Bilateral loss of motor function below the level of the lesion. b. Contralateral motor loss below the level of the lesion. c. Loss of motor power and sensation in the upper extremities bilaterally. d. Ipsilateral loss of touch, pressure and vibration below the level of the lesion.
D
Which condition occurs when blood collects between the dura mater and arachnoid membrane? a. Intracerebral hemorrhage b. Epidural hematoma c. Extradural hematoma d. Subdural hematoma
D
boy was brought to the emergency department (ED) by his father g an apparent concussion during a game. Assessment in the ED Fathers care. What he useducation should he nurse provide to he boys is a. The boy should sleep with his head elevated for the next 2 nights. b. Short-term difficulty in speaking should be expected and will resolve over the next few days. c. The boy should not be given ASA, acetaminophen, or ibuprofen for the next 48 hours. d. The father should awaken his son every 2 hours during the night.
D
