NUR424 Chapter 68 Prep-U
Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane?
A subdural hematoma is bleeding between the dura mater and arachnoid membrane. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with displacement of surrounding structures.
Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?
Any patient with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.
Which of the following is not a manifestation of Cushing's Triad?
Cushing's triad is manifested by bradycardia, hypertension, and bradypnea. Tachycardia is not a component of the triad.
While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist's diagnosis to be?
A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence.
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?
A fracture of the base of the skull is referred to as a basilar skull fracture. 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.
The ED nurse is receiving a patient-handoff report at the beginning of the nursing shift. The departing nurse notes a patient with a head injury has Battle's sign. The nurse will expect which of the following clinical manifestation?
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, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign).
A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?
Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries).
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.
LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient's responses are rated on a scale from 3 to 15.
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?
The nurse should maintain cerebral perfusion pressure from 50 to 70 mm Hg to aid in controlling increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the patient's head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners.
Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels?
Transcranial Doppler flow studies are used to study a tumor's blood flow within intracranial blood vessels. Cerebral angiography may be used to study a tumor's blood supply or obtain information about vascular lesions
You are a neuro trauma 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?
Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury.
A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified?
Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury. This describes a client with an acute subdural hematoma.
A male client on a neurologic unit is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for his condition, he is unable to move his lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Expected outcomes of care would include all of the following, except?
A client with a lumbar spinal injury would not require mechanical ventilation. This would be an expected outcome of care for a client with a spinal injury.
A patient in the ER has bruising over the mastoid bone and rhinorrhea. The triage nurse suspects the patient has which type of skull fracture?
An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. Basilar skull fractures are also suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).
A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan?
Because the client is disoriented and restless, the most important nursing diagnosis is Risk for injury.
A patient in the emergency room has bruising over the mastoid bone and rhinorrhea. These are indicative of which type of skull fracture?
Bruising over the mastoid bone and rhinorrhea is indicative of a basilar skull fracture. A simple (linear) fracture is a break in the continuity of the bone. A comminuted fracture refers to a splintered or multiple fracture line.
A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bruising can result if the force is strong enough to send the brain ricocheting to the opposite side of the skull, which is called a contrecoup injury.
The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for?
An epidural hematoma is considered an extreme emergency; marked neurologic deficit or even respiratory arrest can occur within minutes. Treatment consists of making openings through the skull to decrease intracranial pressure emergently, remove the clot, and control the bleeding.
The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first?
Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid.