ICP

Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?

Transcranial Doppler

The nurse has documented a client diagnosed with a head injury as having a Glasgow Coma Scale (GCS) score of 7. This score is generally interpreted as

coma.

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered

low.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure?

vasodilation

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)?

Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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?

Being an athlete

When caring for a client who is post-intracranial surgery what is most important parameter to monitor?

Body temperature

While making initial rounds after coming on shift, the nurse finds a client thrashing about in bed with a severe headache. The client tells the nurse the pain is behind the right eye, which is red and tearing. What type of headache would the nurse suspect this client of having?

Cluster

The critical care nurse is caring for a client with bacterial meningitis. The client has developed cerebral vasculitis and increased ICP. What neurologic sequelae might this client develop?

Damage to the optic nerve

Which of the following is an early sign of increasing intracranial pressure (ICP)?

Headache

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

Ineffective airway clearance related to brain injury

Which is the priority nursing diagnosis when caring for a client with increased ICP who has an intraventricular catheter?

Ineffective cerebral tissue perfusion

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?

Irrigates the wound to remove debris.

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Midbrain

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

The client has cerebral spinal fluid (CSF) leaking from the ear.

The Monro-Kellie hypothesis refers to which of the following?

The dynamic equilibrium of cranial contents

Neurological level of spinal cord injury refers to which of the following?

The lowest level at which sensory and motor function is normal.

A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require?

The patient will be able to ambulate independently.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

Traction with weights and pulleys

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 priority nursing action? You Selected:

Administer acetaminophen per orders.

he nurse is completing an assessment on a client with myasthenia gravis. Which of the following historical recounting provides the most significant evidence regarding when the disorder began?

Drooping eyelids

A client is brought to the emergency department with multiple fractures. Which assessment finding would be most significant in determining the client has also suffered a closed head injury with rising intracranial pressure?

Lethargy

The most important nursing priority of treatment for a patient with an altered LOC is to:

Maintain a clear airway to ensure adequate ventilation.

A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for?

Rebound hypotension.

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:

Severe TBI.

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?

18 to 36 hours

Cerebral edema peaks at which time point after intracranial surgery?

24 hours

A client with tetraplegia has a spinal cord injury (SCI) at C4. He experiences severe orthostatic hypotension with any elevation of his head. Which of the following interventions will the nurse employ to reduce the hypotension?

Apply anti-embolic stockings prior to elevation of the head.

A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best?

Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes.

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

Basilar

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?

Body temperature

A nurse is working in the neurologic intensive care unit and admits from the emergency department a patient with an inoperable brain tumor. Upon entering the room, the nurse observes that the patient is positioned with arms flexed, pronated, and extended and straight down by side. Which posturing is the patient exhibiting?

Decerebrate

A patient brought to the hospital after a skiing accident was unconscious for a brief period of time at the scene, then woke up disoriented and refused to go to the hospital for treatment. The patient became very agitated and restless, then quickly lost consciousness again. What type of TBI is suspected in this situation?

Epidural hematoma

The nurse is caring for a client with an inoperable brain tumor. What teaching is important for the nurse to do with these clients?

Explaining hospice care and services

A patient has a severe neurologic impairment from a head trauma. What does the nurse recognize is the type of posturing that occurs with the most severe neurologic impairment?

Flaccid

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?

Flat, except for logrolling as needed.

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:

Glasgow Coma Scale of 6

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

Place the client in a sitting position.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

Placing a blanket over the client

A client recovering from a stroke is diagnosed with pseudobulbar affect. Which medication(s) will the nurse prepare teaching on for this client? Select all that apply.

Quinidine sulfate, Dextromethorphan hydrobromide

A nurse is assessing pain in a client who has a spinal cord injury. The client states that even a light touch to the legs will illicit severe pain. The client is describing which type of pain?

allodynia

A nurse is caring for client diagnosed with Huntington disease. The client's plan of care includes interventions to address the client's potential for injury. Which would be included as a cause for this risk?

choreiform movements

A client with a spinal cord injury and subsequent urine retention receives intermittent catheterization every 4 hours. The average catheterized urine volume has been 550 ml. The nurse should plan to:

increase the frequency of the catheterizations.

Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers?

Meticulous cleanliness

The nurse is caring for a client with a traumatic brain injury who has developed increased intracranial pressure resulting in syndrome of inappropriate antidiuretic hormone (SIADH). While assessing this client, the nurse expects which of the following findings?

Oliguria and serum hyponatremia

After striking his head on a tree while falling from a ladder, a client is admitted to the emergency department. He's unconscious and his pupils are nonreactive. Which intervention should the nurse question?

Performing a lumbar puncture