NUR1306 Test #2 QUESTIONS Neurology

A nurse is collecting data from a client who has increased ICP. Which of the following findings should the nurse expect? Select all that apply 1. Disoriented to time and place 2. Restlessness and irritability 3. Unequal pupils 4. ICP 15 mmHg 5. Headache

1, 2, 3 and 5

Which of the following is a late sign of increased ICP? 1. Altered respiratory patterns 2. Irritability 3. Headache 4. Slowing of speech

1. Altered respiratory patterns The other three options are early signs of increased ICP.

A patient with increased ICP has a cerebral perfusion pressure of 40 mmHg. How should the nurse interpret the CPP? 1. The CPP is low 2. The CPP reading is inaccurate 3. The CPP is within normal limits 4. The CPP is high

1. The CPP is low Normal CPP is 70 to 100 mmHg

Which of the following medication classifications is utilized to preoperatively to decrease the risk of postoperative seizures? 1. Diuretics 2. Anticonvulsants 3. Corticosteroids 4. Anti-anxiety

2. Anticonvulsants

Which of the following types of posturing is exhibited by abnormal flexion of the upper extremities and plantar flexion of the feet? 1. Normal 2. Decerebrate 3. Decorticate 4. Flaccid

3. Decorticate

Which of the following conditions occurs when bleeding occurs between the dura matter and arachnoid membrane? 1. Epidural hematoma 2. Extradural hematoma 3. Subdural hematoma 4. Intra-cerebral hemorrhage

3. Subdural hematoma

When the nurse observes that the patient has extension and X ternal 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? 1. Decorticate 2. Flaccid 3. Normal 4. Decerebrate

4. Decerebrate

A client with a C6 spinal injury would most likely have which of the following symptoms? 1. Aphasia 2. Hemiparesis 3. Paraplegia 4. Tetraplegia

4. Tetraplegia

A 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 will the nurse at the infusion pump?

80 mL/hr

Which of the following are used to help reduce ICP? 1. Using a cervical collar 2. Keeping the head of bed flat 3. Rotating the neck to the far right with neck support 4. Extreme hip flexion supported by pillows

1. Using a cervical collar Use of a cervical collar promotes venous drainage and prevents jugular vein distortion which can increase ICP.

The nurse is caring for a patient who is being assessed for brain death. Which of the following are cardinal signs of brain death? Select all that apply 1. Coma 2. No brain waves 3. Apnea 4. Absence of brainstem reflexes

1, 3 and 4

Which of the following are risk factors for a spinal cord injury? Select all that apply 1. Alcohol use 2. Caucasian ethnicity 3. Young age 4. Drug abuse 5. Female gender

1, 3 and 4

A nurse is reviewing a prescription for dexamethasone with a client who has an expanding brain tumor. Which of the following are appropriate statements by the nurse? Select all that apply 1. "It is given to reduce swelling of the brain." 2. "You will need to monitor for low blood sugar." 3. "You may notice weight gain." 4. "Tumor growth will be delayed." 5. "It can cause you to retain fluids."

1, 3 and 5

A nurse is caring for a client who is at risk for increased ICP. Which of the following actions should the nurse take to decrease the potential for raising the client's ICP? Select all that apply 1. Suction the client frequently 2. Decrease the noise level in the client's room 3. Elevate the client's head on two pillows 4. Administer a stool softener 5. Keep the client well hydrated

2 and 4 Suctioning should be PRN Avoid hyper flexion of the neck Avoid over hydrating because it can increase ICP

The following statements match nursing interventions with nursing diagnosis. Which statements are true for a patient who has suffered a head injury? Select all that apply 1. Ineffective cerebral tissue perfusion: maintaining cerebral perfusion pressure less than or equal to 50 mmHg 2. Disturbed sleep pattern: provide the patient with back rubs 3. Interrupted family process: encourage family to join a support group 4. Ineffective airway clearance: suction patient as indicated 5. Deficient fluid volume: administer 1 L of normal saline daily

2, 3 and 4

Which of the following activities would a patient with a T4 spinal cord injury be able to perform independently? Select all that apply 1. Ambulating 2. Writing 3. Breathing 4. Eating 5. Transferring to a wheelchair

2, 3, 4 and 5

The nurse is caring for an 82-year-old patient diagnosed with cranial arteritis. What is the priority nursing intervention? 1. Assess for weight loss 2. Administer corticosteroids as ordered 3. Give acetaminophen per orders 4. Document signs and symptoms of inflammation

2. Administer corticosteroids as ordered Cranial arteritis is caused by inflammation. The inflammation can lead to visual impairment or rupture of the vessel.

A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs? 1. Bloody drainage from the ears 2. Frequent swallowing 3. Guaiac-positive stools 4. Hematuria

2. Frequent swallowing Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.

A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons? 1. To hasten wound healing 2. To immobilize the cervical spine 3. To prevent autonomic dysreflexia 4. To hold bony fragments of the skull together

2. To immobilize the cervical spine Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.

A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP? 1. Place her in a jacket restraint 2. Wrap her hands in soft "mitten" restraints 3. Tuck her arms and hands under the draw sheet 4. Apply a wrist restraint to each arm

2. Wrap her hands in soft "mitten" restraints It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client's arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

A patient experiences a seizure while hospitalized for appendicitis. During the postictal phase, the patient is yelling and swings with a closed fist at the nurse. Which of the following is the appropriate action for the nurse to take? 1. Place the patient in wrist restraints 2. Apply oxygen via nasal cannula 3. Re-orient the patient while gently holding the arms 4. Administer lorazepam per orders

3. Re-orient the patient while gently holding the arms. It was not an intentional reaction and most patients do not remember becoming agitated.

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? 1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) 2. Emergent; the client is poorly oxygenated. 3. Normal 4. Significant; the client has alveolar hypoventilation.

1. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP) A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels.

The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer: 1. Desmopressin (DDAVP, stimate) 2. Dexamethasone (Decadron) 3. Ethacrynic acid (Edecrin) 4. Mannitol (Osmitrol)

1. Desmopressin A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin.

Which neurotransmitter is responsible for may of the functions of the frontal lobe? 1. Dopamine 2. GABA 3. Histamine 4. Norepinephrine

1. Dopamine The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it's such an important neurotransmitter in schizophrenia.

A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client's vital signs, list in order of priority, the nurse's actions (Number 1 being the first priority and number 5 being the last priority). A. Check for bladder distention B. Raise the head of the bed C. Contact the physician D. Loosen tight clothing on the client E. Administer an antihypertensive medication B, D, A, C, E. 1. A, B, C, D, E 2. B, D, A, C, E. 3. C, A, D, E, B 4. C, D, A, B, E

2. B, D, A, C, E.

Which of the following is the earliest sign of increasing ICP? 1. Headache 2. Change in LOC 3. Vomiting 4. Posturing

2. Change in LOC

The nurse is caring for a patient following and SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction? 1. "I will change the vessel liner often." 2. "I can apply powder under the liner to help with sweating." 3. "If a pin becomes detached, I'll notify the surgeon." 4. "I'll check under the liner for blisters and redness."

3. "I'll check under the liner for blisters and redness."

Which is the highest priority nursing diagnosis when caring for a patient with increased ICP who has an intraventricular catheter? 1. Risk for infection 2. Fluid volume deficit 3. Ineffective cerebral tissue perfusion 4. Risk for injury

3. Ineffective cerebral tissue perfusion The brain must be adequately perfused to maintain function and prevent long-term disability due to lack of oxygenation.

The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP? 1. Administering enemas, as needed 2. Positioning the patient in the supine position 3. Maintaining cerebral perfusion pressure from 50 to 70 mmHg 4. Restraining the patient, as indicated

3. Maintaining cerebral perfusion pressure from 50 to 70 mmHg Other measures include elevating the head of the bed as prescribed, maintaining the patient's head and neck a neutral alignment, initiating measures to present a Valsalva maneuver, stool softeners, maintaining body temperature within normal limits, administering oxygen to maintain PaO2 greater than 90 mmHg, maintaining fluid balance with normal saline, avoiding noxious stimuli, administering sedation to reduce agitation.

A nurse is assisting with the care of a client following surgical evacuation of a sub dural hematoma. Which of the following data is the priority to monitor? 1. Glasgow coma scale 2. Cranial nerve function 3. Oxygen saturation 4. Pupillary response

3. Oxygen saturation

The nurse is caring for a patient following a head injury. The nurse understands that the patient is at risk for post traumatic seizures. A seizure that is classified as early occurs within which time frame? 1. Less than seven days following surgery 2. Four hours of injury 3. 24 hours of injury 4. 1 to 7 days of injury

4. 1 to 7 days of injury Post traumatic seizures are immediate, within 24 hours of injury, early, within 1 to 7 days after injury, or late, more than seven days after injury.

The nurse is caring for a patient with a spinal cord lesion above T6. Which of the following stimuli is known to trigger an episode of autonomic dysreflexia? 1. Diarrhea 2. Voiding 3. Placing the patient in a sitting position 4. Applying a blanket over the patient

4. Applying a blanket over the patient And object on the skin or skin pressure may precipitate an autonomic dysreflexia episode. Distended bladder, distention or contraction of the visceral organs, bowel constipation, stimulation of the skin are all noxious stimuli. Once the trigger is removed, and the patient is placed in a sitting position, the blood pressure should immediately lower.

Which of the following describes decerebrate posturing? 1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers 2. Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet 3. Supination of arms, dorsiflexion of feet 4. Back arched; rigid extension of all four extremities.

4. Back arched; rigid extension of all four extremities. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply. 1. Elevate the HOB to 90 degrees 2. Loosen constrictive clothing 3. Use a fan to reduce diaphoresis 4. Assess for bladder distention and bowel impaction 5. Administer antihypertensive medication

1, 2, 4 and 5 The client has S/S of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn't reduce the client's blood pressure, IV antihypertensives should be administered. A fan shouldn't be used because cold drafts may trigger autonomic dysreflexia.

Which interventions are appropriate for a patient with increased ICP? Select all that apply 1. Elevating the head of the bed at 90° 2. Maintaining aseptic technique with the intraventricular catheter 3. Frequent oral care 4. Administering prescribed antipyretics 5. Encouraging deep breathing and coughing every two hours

2, 3 and 4

A nurse is caring for a client who has a benign brain tumor. The client asks the nurse if he can expect the same type of tumor to occur in other areas of his body. Which of the following is an appropriate response by the nurse? 1. "It can spread to breasts and kidneys." 2. "It can develop in your gastrointestinal tract." 3. "It is limited to brain tissue." 4. "It probably started in another area of your body and spread to your brain."

3. "It is limited to brain tissue."

An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions? 1. "Watch him for keyhole pupil the next 24 hours." 2. "Expect profuse vomiting for 24 hours after the injury." 3. "Wake him every hour and assess his orientation to person, time, and place." 4. "Notify the physician immediately if he has a headache."

3. "Wake him every hour and assess his orientation to person, time, and place." Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. Severe or worsening headaches should be reported.

A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest? 1. Subdural hematoma 2. Subarachnoid hemorrhage 3. Epidural hematoma 4. Contusion

3. Epidural hematoma In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain's surface.

A patient arrives at the emergency department via ambulance following a motorcycle accident. The paramedics state that the patient was found unconscious at the scene of the accident, but briefly regained consciousness during transport to the hospital. Upon initial assessment, the patient's GCS is seven. The nurse anticipates which of the following? 1. An order for a head CT scan 2. Intubation and mechanical ventilation 3. Immediate craniotomy 4. Administration of propofol Diprivan by IV

3. Immediate craniotomy The patient is experiencing an epidural hematoma - it is an extreme emergency. Treatment consists of making burr holes to decrease ICP, remove the clot and control the bleeding. They are often characterized by a brief loss of consciousness followed by a lucid interval in which the patient is awake and conversant. During the lucid interval, compensation for the expanding hematoma takes place by rapid absorption of CSF and decreased intravascular volume. When they can no longer compensate, even a small increase in the volume of blood produces a marked elevation an ICP. The patient then becomes increasingly restless, agitated and confused as the progressive condition becomes a coma.

A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given? 1. "Clean the meatus from back to front." 2. "Measure the quantity of urine." 3. "Gently rotate the catheter during removal." 4. "Clean the meatus with soap and water."

4. "Clean the meatus with soap and water." Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus.

A nurse is reviewing the health record of a client who has a malignant brain tumor and notes the client has a positive Romberg sign. Which of the following actions should the nurse take to check for this manifestation? 1. Stroke the lateral aspect of the sole of the foot 2. Ask the client to blink his eyes 3. Observe for facial drooping 4. Have the client stand erect with eyes closed.

4. Have the client stand erect with eyes closed.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence? 1. Strict adherence to a bowel retraining program 2. Limiting bladder catheterization to once every 12 hours 3. Keeping the linen wrinkle-free under the client 4. Preventing unnecessary pressure on the lower limbs

2. Limiting bladder catheterization to once every 12 hours The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing.

The nurse is assigned to care for patients with spinal cord injuries on rehabilitation unit. Which of the following does the nurse recognize are clinical manifestations of autonomic dysreflexia? Select all that apply 1. Nasal congestion 2. Fever 3. Diaphoresis 4. Tachycardia 5. Hypertension

1, 3 and 5 Bradycardia, not tachycardia occurs with autonomic dysreflexia.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? 1. Evaluate urine specific gravity 2. Anticipate treatment for renal failure 3. Provide emollients to the skin to prevent breakdown 4. Slow down the IV fluids and notify the physician

1. Evaluate urine specific gravity Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected? 1. Autonomic dysreflexia 2. Hypervolemia 3. Neurogenic shock 4. Sepsis

3. Neurogenic shock Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock.

A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? 1. Laceration of the middle meningeal artery 2. Rupture of the carotid artery 3. Thromboembolism from a carotid artery 4. Venous bleeding from the arachnoid space

1. Laceration of the middle meningeal artery Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.

A nurse is conducting health fair on spinal cord injuries at a local high school. The nurse relays that which of the following is the most common cause of spinal cord injury? 1. MVA 2. Sports related injuries 3. Falls 4. Acts of violence

1. MVA

After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect? 1. Quadriplegia with gross arm movement and diaphragmatic breathing 2. Quadriplegia and loss of respiratory function 3. Paraplegia with intercostal muscle loss 4. Loss of bowel and bladder control

1. Quadriplegia with gross arm movement and diaphragmatic breathing A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.

An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first? 1. Reposition the client to avoid neck flexion 2. Administer 1 g Mannitol IV as ordered 3. Increase the ventilator's respiratory rate to 20 breaths/minute 4. Administer 100 mg of pentobarbital IV as ordered.

1. Reposition the client to avoid neck flexion The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.

Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations 2. Rapid, shallow respirations 3. Asymmetric chest expansion 4. Nasal flaring

1. Slow, irregular respirations Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor? 1. Unequal pupil size 2. Decreasing systolic blood pressure 3. Tachycardia 4. Decreasing body temperature

1. Unequal pupil size Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.

A nurse is caring for a patient immediately following a spinal cord injury. Which of the following is an acute complication of spinal cord injury? 1. Spinal shock 2. Paraplegia 3. Tetraplegia 4. Cardiogenic shock

1. Spinal shock Acute complications of Spinal cord injuries include spinal and neurogenic shock and deep vein thrombosis.

A female patient with meningitis has a history of seizures. Which of the following actions by the nurse is appropriate while the patient is actively seizing? 1. Turn the patient to the side 2. Place a cooling blanket 3. Administer mannitol 4. Insert oral airway

1. Turn the patient to the side

A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition? 1. Widening pulse pressure 2. Decrease in the pulse rate 3. Dilated, fixed pupil 4. Decrease in LOC

4. Decrease in LOC A decrease in the client's LOC is an early indicator of deterioration of the client's neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.

A patient has been diagnosed with a concussion. The patient is preparing to be discharge from the emergency department. The nurse teaches the family members who will be caring for the patient to contact the physician or return to the ED if the patient demonstrates or complains of which of the following? Select all that apply 1. Sleeps for short periods of time 2. Slurred speech 3. Vomiting 4. Weakness on one side of the body 5. Headache

2, 3 and 4 A decrease in LOC, worsening headache, dizziness, seizures, abnormal people response, vomiting, irritability, slurred speech, numbness or weakness in the arms or legs should be reported immediately. Also, difficulty in waking the patient.

A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply. 1. Decerebrate posturing 2. Dilated nonreactive pupils 3. Deep tendon reflexes 4. Absent corneal reflex

2, 3 and 4 A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death.

The nurse has documented a patient diagnosed with a head injury as having a GCS score of seven. The score is generally interpreted as which of the following? 1. Minimally responsive 2. Coma 3. Least responsive 4. Most responsive

2. Coma

In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicated when positioning the client? 1. Keeping the client flat on one side or the other 2. Elevating the head of the bed to 30 degrees 3. Log rolling or turning as a unit when turning 4. Keeping the head in neutral position

2. Elevating the head of the bed to 30 degrees Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brainstem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used for supratentorial craniotomies.

The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for: 1. A flattened abdomen 2. Hematest positive nasogastric tube drainage 3. Hyperactive bowel sounds 4. A history of diarrhea

2. Hematest positive nasogastric tube drainage After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool.

A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated? 1. Decreased urine output or oliguria 2. Hypertension and bradycardia 3. Respiratory depression 4. Symptoms of shock

2. Hypertension and bradycardia Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge.

The nurse is caring for a patient immediately following supratentorial intra-cranial surgery. What action by the nurse is appropriate? 1. Place patient in prone position with head turned to unaffected side 2. Place patient in supine position with head slightly elevated 3. Placed patient in the dorsal recumbent position 4. Placed patient in the Trendelenberg position

2. Placed patient in supine position with head slightly elevated. Alternatively, the patient could be put in a side lying position on the unaffected side. All other positions would increase intercranial pressure.

A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose? 1. Therapeutic drug levels should be maintained between 20 to 30 mg/ml. 2. Rapid dilantin administration can cause cardiac arrhythmias. 3. Dilantin should be mixed in dextrose in water before administration. 4. Dilantin should be administered through an IV catheter in the client's hand.

2. Rapid dilantin administration can cause cardiac arrhythmias. Dilantin IV shouldn't be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn't be mixed in solution for administration. When given through an IV catheter hand, dilantin may cause purple glove syndrome.

Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury? 1. Insert an indwelling urinary catheter to straight drainage 2. Schedule intermittent catheterization every 2 to 4 hours 3. Perform a straight catheterization every 8 hours while awake 4. Perform Crede's maneuver to the lower abdomen before the client voids.

2. Schedule intermittent catheterization every 2 to 4 hours Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible.

A female patient is receiving hypothermic treatment for uncontrolled fever is related to increased intracranial pressure ICP. Which of the following assessment findings requires immediate intervention? 1. Urine output of 100 mL per hour 2. Shivering 3. Cool, dry skin 4. Capillary refill of two seconds

2. Shivering Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption.

Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia? 1. Absence of pain sensation in chest 2. Spasticity 3. Spontaneous respirations 4. Urinary continence

2. Spasticity Spasticity, the return of reflexes, is a sign of resolving shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.

The Monro-Kellie hypothesis refers to which of the following statements? 1. The brain's unresponsiveness to the environment 2. The dynamic equilibrium of cranial contents 3. The patient being wakeful but devoid of conscious content, without cognitive or affective mental function 4. The brains attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure

2. The dynamic equilibrium of cranial contents. The theory states that because of the limited space for expansion with in the school, and increase in any one of the cranial contents causes a change in the volume of the others.

The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions? 1. Extent of intracranial bleeding 2. Sites of brain injury 3. Activity of the brain 4. Percent of functional brain tissue

3. Activity of the brain

The nurse is caring for a male patient who has emerged from a coma following a head injury. The patient is agitated. Which of the following interventions will the nurse implement to prevent patient injury? 1. Turning and repositioning the patient every two hours 2. Administering opioids to control restlessness 3. Applying an external urinary sheath catheter 4. Providing a dimly lit room to prevent visual hallucinations

3. Applying an external urinary sheath catheter

The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury? 1. Monitoring vital signs before and during position changes 2. Using vasopressor medications as prescribed 3. Moving the client quickly as one unit 4. Applying Teds or compression stockings.

3. Moving the client quickly as one unit Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client's position slowly.

Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. Give the client a warming blanket 2. Administer low-dose barbiturate 3. Encourage the client to hyperventilate 4. Restrict fluids

3. Encourage the client to hyperventilate Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? 1. Auto regulation 2. Cushing's response 3. Herniation 4. Monro-Kellie hypotheses

3. Herniation

A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first? 1. Assess full ROM to determine extent of injuries 2. Call for an immediate chest x-ray 3. Immobilize the client's head and neck 4. Open the airway with the head-tilt chin-lift maneuver

3. Immobilize the client's head and neck All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence.

The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists? 1. Positive reflexes 2. Hyperreflexia 3. Inability to elicit a Babinski's reflex 4. Reflex emptying of the bladder

3. Inability to elicit a Babinski's reflex Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski's reflex.

While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions? 1. Autonomic dysreflexia 2. Hemorrhagic shock 3. Neurogenic shock 4. Pulmonary embolism

3. Neurogenic shock Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with *autonomic dysreflexia*. *Hemorrhagic shock* presents with anxiety, tachycardia, and hypotension; this wouldn't be suspected without an injury. *Pulmonary embolism* presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority? 1. Bladder distension 2. Neurological deficit 3. Pulse ox readings 4. The client's feelings about the injury

3. Pulse ox readings After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.

Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? 1. Diffuse axonal injury 2. Intracranial hemorrhage 3. Concussion 4. Contusion

4. Contusion 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. Hemorrhage and edema peak after about 18 to 36 hours.

Which of the following should be avoided in patients with increased ICP? 1. Position changes 2. Suctioning 3. Minimal environmental stimuli 4. Enemas

4. Enemas The Valsalva maneuver can cause increased ICP.

Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? 1. Subdural 2. Intra-cerebral 3. Diffuse axonal injury 4. Epidural

4. Epidural

The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with: 1. Skull fracture 2. Concussion 3. Subdural hematoma 4. Epidural hematoma

4. Epidural hematoma The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client's neurological status deteriorates quickly.

The nurse is caring for a patient with a head injury. The patient is experiencing CSF rhinorrhea. Which of the following orders should the nurse question? 1. Out of bed to chair three times a day 2. Serum sodium level 3. Urine testing for acetone 4. Insertion of a nasogastric tube

4. Insertion of a nasogastric tube With CSF rhinorrhea, an oral feeding tube should be inserted instead of a nasal tube.

A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia? 1. Headache 2. Lumbar spinal cord injury 3. Neurogenic shock 4. Noxious stimuli

4. Noxious stimuli Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn't a cause of dysreflexia.

The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by: 1. Keeping the client on a stretcher 2. Logrolling the client on a firm mattress 3. Logrolling the client on a soft mattress 4. Placing the client on a Stryker frame

4. Placing the client on a Stryker frame Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.

The nurse is caring for a patient with a Trumatic brain injury. The nurse notes the following clinical findings during the reassessment of the patient. Which of the following will cause the nurse the most concern? 1. Urinary output increases from 40 mL an hour to 55 mL an hour 2. Heart rate decreases from 100 bpm to 90 bpm 3. Pulse oximetry decreases from 99% room air to 97% room air 4. Temperature increases from 98°F to 99.6°F

4. Temperature increases from 98°F to 99.6°F Fever in a patient with a TBI can be a result of damage to the hypothalamus, cerebral irritation from him Ridge or infection. The nurse should monitor the patient's temperature every 2 to 4 hours

A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase? 1. Absent corneal reflex 2. Decerebrate posturing 3. Movement of only the right or left half of the body 4. The need for mechanical ventilation

4. The need for mechanical ventilation The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. The other options occur with brain injuries, not spinal cord injuries.

An osmotic diuretic, such as mannitol, is given to the patient with increased ICP for which of the following therapeutic effects? 1. To reduce cellular metabolic demands 2. To lower uncontrolled fevers 3. To increase urine output 4. To dehydrate the brain and reduce cerebral edema

4. To dehydrate the brain and reduce cerebral edema

Which of the following findings in the patient who has sustained a head injury indicates increasing ICP? 1. Decreased respirations 2. Decreased body temperature 3. Increased pulse 4. Widened pulse pressure

4. Widened pulse pressure The Cushing triad is bradycardia, increasing systolic blood pressure and widening pulse pressure.

A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord? 1. Acetazolamide (Diamox) 2. Furosemide (Lasix) 3. Methylprednisolone (Solu-Medrol) 4. Sodium bicarbonate

3. Methylprednisolone (Solu-Medrol) High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit.

A 23-year-old patient with a recent history of encephalitis is admitted to the medical unit with new onset generalized tonic-clonic seizures. Which nursing activities included in the patient's care will be best to delegate to an LPN/LVN whom you are supervising? 1. Document the onset time, nature of seizure activity, and postictal behaviors for all seizures. 2. Administer phenytoin (Dilantin) 200 mg PO daily. 3. Teach patient about the need for good oral hygiene. 4. Develop a discharge plan, including physician visits and referral to the Epilepsy Foundation.

2. Administer phenytoin (Dilantin) 200 mg PO daily. Administration of medications is included in LPN education and scope of practice. Collection of data about the seizure activity may be accomplished by an LPN/LVN who observes initial seizure activity. An LPN/LVN would know to call the supervising RN immediately if a patient started to seize. Documentation of the seizure, patient teaching, and planning of care are complex activities that require RN level education and scope of practice.

A patient in the ER has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the patient has what type of skull fracture? 1. Comminuted 2. Basilar 3. Simple 4. Linear

2. Basilar Basilar skull fractures are also suspected when CSF escapes from the ears and the nose.

A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate? 1. Count the rate to be sure the ventilations are deep enough to be sufficient 2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. 3. Call the physician to adjust the ventilator settings. 4. Check deep tendon reflexes to determine the best motor response

2. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.

The nurse is caring for a patient with a ventriculostomy. Which assessment finding documented demonstrates effectiveness of the ventriculostomy? 1. The pupils are dilated and fixed. 2. ICP is 12 mmHg 3. The mean arterial pressure is equal to the intracranial pressure 4. Cerebral perfusion pressure is 21 mmHg

2. ICP is 12 mmHg Normal ICP is 0 to 50 mmHg 12 mmHg would demonstrate the effectiveness of the ventriculostomy.

Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia? 1. A client with a brain injury 2. A client with a herniated nucleus pulposus 3. A client with a high cervical spine injury 4. A client with a stroke

3. A client with a high cervical spine injury Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren't prone to dysreflexia.

The ED nurse is receiving a patient handoff report at the beginning of the nursing shift. The departing nurse noted patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestations? 1. Escape of CSF from the patient's nose 2. Escape of CSF from the patient's ear 3. An area of bruising over the mastoid bone 4. A bloodstain surrounded by a yellowish stain on the head dressing

3. An area of bruising over the mastoid bone Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, fair next, ears and blood may appear under the conjunctiva. An area of ecchymosis may be seen over the mastoid.

During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions? 1. Elevate the client's legs 2. Put the client flat in bed 3. Put the client in the Trendelenburg's position 4. Put the client in the high-Fowler's position

4. Put the client in the high-Fowler's position Putting the client in the high-Fowler's position will decrease cerebral blood flow, decreasing hypertension. All of the other options will increase hypertension.

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? 1. Place the client flat in bed 2. Assess patency of the indwelling urinary catheter 3. Give one SL nitroglycerin tablet 4. Raise the head of the bed immediately to 90 degrees

4. Raise the head of the bed immediately to 90 degrees Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised.

A patient with neurologic infection develops cerebral edema from syndrome of inappropriate antidiuretic hormone SIADH. Which of the following is an important nursing action for this patient? 1. Maintaining adequate hydration 2. Administering prescribed antipyretics 3. Hyper oxygenation before and after tracheal suctioning 4. Restricting fluid intake and hydration

4. Restricting fluid intake and hydration

After a hypophysectomy, vasopressin is given IM for which of the following reasons? 1. To treat growth failure 2. To prevent syndrome of inappropriate antidiuretic hormone (SIADH) 3. To reduce cerebral edema and lower intracranial pressure 4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.

4. To replace antidiuretic hormone (ADH) normally secreted by the pituitary. After hypophysectomy, or removal of the pituitary gland, the body can't synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.

A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first? 1. Position the client flat in bed 2. Check the fluid for dextrose with a dipstick 3. Suction the nose to maintain airway patency 4. Insert nasal and ear packing with sterile gauze

2. Check the fluid for dextrose with a dipstick Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn't be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.

Cerebral edema peaks at which time frame after intra-cranial surgery? 1. 48 hours 2. 72 hours 3. 24 hours 4. 12 hours

3. 24 hours Cerebral edema tends to peak 24 to 36 hours after surgery

The nurse is caring for a patient involved in a motorcycle accident seven days ago. Since admission the patient has been on responsive to painful stimuli. The patient had a ventriculostomy placed upon admission to the ICU. The current assessment findings include ICP a 14 with good waveforms, pulse 92, respirations per vent to later, temperature of 102.7°F rectal, urine output 320 mL in four hours, pupils pin point and briskly reactive, and hot dry skin. Which of the following is the priority nursing action? 1. Inspect the ICP monitor to ensure it is working properly 2. Assess for signs and symptoms of infection 3. Administer Tylenol per orders 4. Provide ventriculostomy care

3. Administer Tylenol per orders Tylenol will help control the fever. An increase in the patient's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated.

When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval? 1. An interval when the client's speech is garbled. 2. An interval when the client is alert but can't recall recent events. 3. An interval when the client is oriented but then becomes somnolent. 4. An interval when the client has a "warning" symptom, such as an odor or visual disturbance.

3. An interval when the client is oriented but then becomes somnolent. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness.

An unresponsive patient is brought to the emergency department by a family member. The family states, "we don't know what happened". Which of the following is the priority nursing intervention? 1. Assess pupils 2. Assess Glasgow coma scale 3. Assess for a patent airway 4. Assess vital signs

3. Assess for a patent airway

A 20-year-old client who fell approximately 30' is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client's airway for rescue breathing? 1. By inserting a nasopharyngeal airway 2. By inserting a oropharyngeal airway 3. By performing a jaw-thrust maneuver 4. By performing the head-tilt, chin-lift maneuver

3. By performing a jaw-thrust maneuver If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.

The nurse is assessing the LOC of a patient who has suffered a head injury. The clients GCS score is 15. Which of the following did the nurse observed to arrive at a score of 15? Select all that apply 1. Bradycardia and hypotension 2. Incomprehensible sounds 3. Obeying motor commands 4. Oriented to person place and time 5. Spontaneous eye-opening 6. Unequal pupils size

3, 4 and 5