Neurologic Trauma ch63

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

30-degree head elevation

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

A change in consciousness.

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Hyperreflexia along with spastic extremities Spasticity of all four extremities Positive Babinski's reflex along with spastic extremities Absence of reflexes along with flaccid extremities

Absence of reflexes along with flaccid extremities

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 Alteration in level of consciousness (LOC) Slurred speech Bradycardia

Alteration in level of consciousness (LOC)

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? Thrombophlebitis Autonomic dysreflexia Orthostatic hypotension Spinal shock

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? Areflexia Autonomic dysreflexia Tetraplegia Paraplegia

Autonomic dysreflexia

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? Basilar Comminuted Depressed Simple

Basilar

For a patient with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO2)? To increase cerebral perfusion pressure To prevent secondary brain injury So that the patient will not have a respiratory arrest Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

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

When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Extreme thirst Intake and output Nutritional status Body temperature

Body temperature

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 with fixed pupils Edema to the head with bruising of the mastoid process Edema to the head and a blackened eye Edema to the head with a large scalp laceration

Edema to the head with bruising of the mastoid process

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client? Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction Disturbed thought processes related to brain injury Ineffective cerebral tissue perfusion related to increased intracranial pressure Ineffective airway clearance related to brain injury

Ineffective airway clearance related to brain injury

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question? Out of bed to the chair three times a day Urine testing for acetone Serum sodium concentration testing Insertion of a nasogastric (NG) tube

Insertion of a nasogastric (NG) tube

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 initial damage to the brain from the traumatic event. It results from inadequate delivery of nutrients and oxygen to the cells. It refers to the permanent deficits seen after the rehabilitation process. 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.

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? Evaluation for signs and symptoms of increased intracranial pressure (ICP) Lung auscultation and measurement of vital capacity and tidal volume Evaluation of pain and discomfort Evaluation of nutritional status and metabolic state

Lung auscultation and measurement of vital capacity and tidal volume

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? Allowing the client to choose the position of comfort Continuous use of an indwelling catheter Avoidance of all lotions and lubricants Meticulous cleanliness

Meticulous cleanliness

Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Assessing laboratory test results as ordered Administering zolpidem tartrate (Ambien) Monitoring the patency of an indwelling urinary catheter Placing the client in Trendelenburg's position

Monitoring the patency of an indwelling urinary catheter

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 Sports-related injuries Acts of violence Motor vehicle crashes Falls

Motor vehicle crashes

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

Subdural

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

Subdural hematoma

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? Let the airway stay as it currently is. Suction the airway. Use mechanical ventilation. Administer oxygen as prescribed.

Suction the airway.

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. Muscle strength Intelligence Verbal response Motor response Eye opening

Verbal response Motor response Eye opening

Which finding indicates increasing intracranial pressure (ICP) in the client who has sustained a head injury? Increased pulse Widened pulse pressure Increased respirations Decreased body temperature

Widened pulse pressure

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? subacute intracerebral chronic acute

acute

Three hours after injuring the spinal cord at the C6 level, a client receives high doses of methylprednisolone sodium succinate (Solu-Medrol) to suppress breakdown of the neurologic tissue membrane at the injury site. To help prevent adverse effects of this drug, the nurse expects the physician to order: atracurium (Tracrium). naloxone (Narcan). nitroglycerin (Nitro-Bid). famotidine (Pepcid).

famotidine (Pepcid).

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 aid in restoring your skeletal integrity." "They prepare you to function in the absence of your leg function." "They help prevent the development of contractures."

"They help prevent the development of contractures."

A client with quadriplegia is in spinal shock. What finding should the nurse expect? Spasticity of all four extremities Absence of reflexes along with flaccid extremities Hyperreflexia along with spastic extremities Positive Babinski's reflex along with spastic extremities

Absence of reflexes along with flaccid extremities

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? Escape of cerebrospinal fluid from the client's ear Escape of cerebrospinal fluid from the client's nose A bloodstain surrounded by a yellowish stain on the head dressing An area of bruising over the mastoid bone

An area of bruising over the mastoid bone

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 Glasgow Coma Scale of 6 Apnea Absence of brain stem reflexes

Glasgow Coma Scale of 6

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. Hypotension Tachycardia Hypertension Bradypnea Bradycardia

Hypertension Bradypnea Bradycardia

A patient was body surfing in the ocean and sustained a cervical spinal cord fracture. A halo traction device was applied. How does the patient benefit from the application of the halo device? The patient can remove it as needed. It allows for stabilization of the cervical spine along with early ambulation. It is less bulky and traumatizing for the patient to use. It is the only device that can be applied for stabilization of a spinal fracture.

It allows for stabilization of the cervical spine along with early ambulation.

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 Look for signs of increased intracranial pressure Emphasize complete bed rest Look for a halo sign

Look for signs of increased intracranial pressure

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? Keep accurate intake and output. Watch closely for signs of urinary tract infection. Avoid range of motion exercises for the client because of spasms. Maintain a diet for the client that is high in protein, vitamins, and calories.

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

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? Pain level Respiratory pattern Pulse and blood pressure Numbness and tingling

Pulse and blood pressure

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

Spinal shock

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? Runny nose Rapid heart rate Sweating Slight headache

Sweating

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? Take daily weights. Assess for pupillary response frequently. Reposition the client frequently. Assess vital signs frequently.

Take daily weights.

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 are getting spinal contractures. They are gaining weight. They need a bath. They have the beginning of a pressure sore.

They have the beginning of a pressure sore.

Which are characteristics of autonomic dysreflexia? severe hypotension, tachycardia, nausea, flushed skin severe hypertension, slow heart rate, pounding headache, sweating severe hypertension, tachycardia, blurred vision, dry skin severe hypotension, slow heart rate, anxiety, dry skin

severe hypertension, slow heart rate, pounding headache, sweating

The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Temporal skull fracture Frontal skull fracture Occipital skull fracture Basilar skull fracture

Basilar skull fracture

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? Bleeding continues into the intracerebral area. Monitoring is needed as rapid neurologic deterioration may occur. The crash cart with defibrillator is kept nearby. Symptoms will evolve over a period of 1 week.

Monitoring is needed as rapid neurologic deterioration may occur.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch? Myoclonus Spasticity Ataxia Akathisia

Spasticity

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? Urinary output increase from 40 to 55 mL/hr Temperature increase from 98.0°F to 99.6°F Heart rate decrease from 100 to 90 bpm Pulse oximetry decrease from 99% to 97% room air

Temperature increase from 98.0°F to 99.6°F

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 sleeps for short periods of time. reports generalized weakness. reports a headache. vomits.

vomits.

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? Cast Traction with weights and pulleys Cervical collar Turning frame

Traction with weights and pulleys