Prep U - Honan - Neurologic Trauma
Which value indicates a normal intracranial pressure (ICP)? 5 mm Hg 17 mm Hg 20 mm Hg 27 mm Hg
5 mm Hg Explanation: ICP is usually measured in the lateral ventricles. Pressure measuring 0 to 10 mm Hg is considered normal. The other values are incorrect.
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 Young age Alcohol/drug use Male gender
Being an athlete Explanation: The predominant risk factors for SCI include young age (most between 16 and 30 years old), gender (80% of those living with SCI are male), and alcohol/drug use.
A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include: diminished responsiveness. elevated temperature. pupillary changes. decreasing blood pressure.
Correct response: diminished responsiveness. Explanation: Usually, diminished responsiveness is the first sign of increasing ICP. Pupillary changes occur later. Increased ICP causes systolic blood pressure to rise. Temperature changes vary and may not occur even with a severe decrease in responsiveness.
Which of the following is an early sign of increasing intracranial pressure (ICP)? Loss of consciousness Vomiting Headache Decerebrate posturing
Headache Explanation: A headache that is constant or increases in intensity is considered an early sign of increasing intracranial pressure (ICP). Loss of consciousness, projectile vomiting, and decerebrate posturing are all later signs of increasing ICP.
Which of the following symptoms are indicative of a rapidly expanding acute subdural hematoma? Select all that apply. Coma Hypotension Tachypnea Decreased reactivity of the pupils Bradycardia Hemiparesis
Hemiparesis Decreased reactivity of the pupils Bradycardia Coma Explanation: Signs and symptoms include changes in the level of consciousness (LOC), changes in the reactivity of the pupils, and hemiparesis (weakness on one side of the body). There may be minor or even no symptoms, with small collections of blood. Coma, increasing blood pressure, decreasing heart rate, and slowing respiratory rate are all signs of a rapidly expanding mass requiring immediate intervention.
The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures? Insertion of a nasogastric tube Digital stimulation A large volume enema Bowel surgery
Insertion of a nasogastric tube Explanation: Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? Myelography Neurologic examination Computed tomography (CT) scan Radiography
Neurologic examination Explanation: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.
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? Hypotension and bradycardia Rising blood pressure and bradycardia Hypertension and narrowing pulse pressure Hypotension and tachycardia
Rising blood pressure and bradycardia Explanation: Late cardiovascular indicators of increased ICP include rising blood pressure, bradycardia, and widening pulse pressure — known collectively as Cushing's triad. Increased ICP usually causes a bounding pulse; as death approaches, the pulse becomes irregular and thready.
Which of the following is not a manifestation of Cushing's triad (Cushing reflex)? Hypertension Widening pulse pressure Irregular respiration Tachycardia
Tachycardia Explanation: Cushing's triad, or Cushing reflex, is a nervous system response to increased intracranial pressure. The client has a slower heart rate (bradycardia), higher systolic blood pressure (hypertension) with lower diastolic pressure (widening pulse pressure), and irregular respiration. More rapid heart rate (tachycardia) is not a component of the triad.
Neurological level of spinal cord injury refers to which of the following? The lowest level at which sensory and motor function is normal The level of the spinal cord transection The best possible level of recovery The highest level at which sensory and motor function is normal
The lowest level at which sensory and motor function is normal Explanation: "Neurologic level" refers to the lowest level at which sensory and motor functions are normal. It is not the level of spinal cord transection, the best possible level of recovery, or the highest level at which sensory and motor function is normal.
Which of the following diagnostic test may be performed to evaluate blood flow within intracranial blood vessels? Cerebral angiography Computed tomography (CT) Magnetic resonance imaging (MRI) Transcranial Doppler
Transcranial Doppler Explanation: 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. An MRI provides information similar to that of a CT scan, but with improved tissue contrast, resolution, and anatomic definition, and examines the lesion in multiple planes.
A gymnast sustained a head injury after falling off the balance beam at practice. The client was taken to surgery to repair an epidural hematoma. In postoperative assessments, the nurse measures the client's temperature every 15 minutes. This measurement is important to: follow hospital protocol. decrease the potential for brain damage. prevent embolism. assess for infection.
decrease the potential for brain damage. Explanation: It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures.
For a client with suspected increased intracranial pressure (ICP), an appropriate respiratory goal is to: prevent respiratory alkalosis. lower arterial pH. promote carbon dioxide elimination. maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg.
promote carbon dioxide elimination. Explanation: The goal of treatment for ICP is to prevent acidemia by eliminating carbon dioxide because an acid environment in the brain causes cerebral vessels to dilate and therefore increases ICP. Preventing respiratory alkalosis and lowering arterial pH may bring about acidosis, an undesirable condition in this client. It isn't necessary to maintain a PaO2 as high as 80 mm Hg; 60 mm Hg will adequately oxygenate most clients.
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? 12 to 24 hours 48 to 72 hours 18 to 36 hours 6 to 8 hours
18 to 36 hours Explanation: Contusions are characterized by loss of consciousness associated with stupor and confusion. 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. The effects of injury (hemorrhage and edema) peak after about 18 to 36 hours.
A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care? client's skin remains clean, dry, and intact client regains bowel elimination capacity client maintains mechanical ventilation with minimal mucus accumulation client reports no discomfort
client maintains mechanical ventilation with minimal mucus accumulation Explanation: A client with a lumbar spinal injury would not require mechanical ventilation.
A client with a neurologic deficit is feeling frustrated because it is very difficult to pronounce words since having a stroke. The client is struggling with: dysphagia. ataxia. dysphasia. dysarthria.
dysarthria. Explanation: Dysarthria is characterized by poor articulation of words due to muscle weakness or loss of muscle control. Dysphasia is characterized by the compromised ability to put words together meaningfully. Ataxia is a dysfunction of the parts of the nervous system that coordinate movement. Dysphagia is difficulty with swallowing.
Which type of hematoma is evidenced by a momentary loss of consciousness at the time of injury, followed by an interval of apparent recovery (lucid interval)? Subdural Epidural Contusion Intracerebral
Epidural Explanation: Symptoms of the epidural hematoma are caused by the expanding hematoma. Usually a momentary loss of consciousness occurs at the time of injury, followed by an interval of apparent recovery (lucid interval). Subdural hematoma is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid.
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? Autoregulation Herniation Cushing's response Monro-Kellie hypothesis
Herniation Explanation: Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing's response is the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.
Which nursing intervention can prevent a client from experiencing autonomic dysreflexia? Administering zolpidem tartrate (Ambien) Assessing laboratory test results as ordered Monitoring the patency of an indwelling urinary catheter Placing the client in Trendelenburg's position
Monitoring the patency of an indwelling urinary catheter Explanation: A full bladder can precipitate autonomic dysreflexia, the nurse should monitor the patency of an indwelling urinary catheter to prevent its occlusion, which could result in a full bladder. Administering zolpidem tartrate, assessing laboratory values, and placing the client in Trendelenburg's position can't prevent autonomic dysreflexia.
A patient has an S5 spinal fracture from a fall. What type of assistive device will this patient require? Voice or sip-n-puff controlled electric wheelchair The patient will be able to ambulate independently. Cane Electric or modified manual wheelchair, needs transfer assistance
The patient will be able to ambulate independently. Explanation: Patients with spinal cord injuries from S1 to S5 should be able to ambulate independently, without an assistive device.
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 hyperosmolarity Oliguria and serum hyponatremia Excessive urine output and serum hyponatremia Excessive urine output and decreased urine osmolality
Oliguria and serum hyponatremia Explanation: SIADH is the result of increased secretion of antidiuretic hormone (ADH). The client becomes volume overloaded, urine output diminishes, and serum sodium concentration becomes dilute.
Which type of hematoma results from a skull fracture that causes a rupture or laceration of the middle meningeal artery? Epidural Subdural Diffuse axonal Intracerebral
Epidural Explanation: An epidural hematoma can result from a skull fracture that causes a rupture or laceration of the middle meningeal artery. A subdural hematoma is a collection of blood between the dura and the brain. An intracerebral hemorrhage is bleeding into the substance of the brain. A diffuse axonal injury involves widespread damage to axons in the cerebral hemispheres, corpus callosum, and brainstem.
A patient is being actively treated for increased intracranial pressure (ICP) in the neurological intensive care unit. The patient's current plan of care includes pharmacological interventions to reduce cellular metabolic demand. The nurse should be aware that this may involve the administration of: Barbiturates Benzodiazepines Beta-adrenergic blockers Anticholinergics
Barbiturates Explanation: Cellular metabolic demands may be reduced through the administration of high doses of barbiturates if the patient is unresponsive to conventional treatment. Benzodiazepines are not used to achieve a reduction in metabolic demand. Anticholinergics and beta blockers do not have this effect.
A patient who has sustained a basal skull fracture is admitted to the neurological unit. The nurse should know that the patient should be observed for: Bleeding from the ears Difficulty sleeping An area of bruising over the mastoid bone An increase in pulse
Bleeding from the ears Explanation: Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone; thus, they frequently produce hemorrhage from the nose, pharynx, or ears. Bruising over the mastoid bone and difficulty sleeping may occur in this patient, but are not areas to be observed for. An increase in pulse would be noted when vital signs are assessed.
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 Medulla Cortex Diencephalon
Midbrain Explanation: Damage to the midbrain causes decerebrate posturing that's characterized by abnormal extension in response to painful stimuli. With damage to the diencephalon or cortex, abnormal flexion (decorticate posturing) occurs when a painful stimulus is applied. Damage to the medulla results in flaccidity.
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? Epidural hematoma Subdural hematoma Intracranial hematoma Extradural hematoma
Epidural hematoma Explanation: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.
Which of the following methods may be used by the nurse to maintain the peripheral circulation in a patient with increased intracerebral pressure (ICP)? Assist the patient with frequent ambulation. Take care not to jar the bed or cause unnecessary activity. Apply elastic stockings to lower extremities. Elevate patient's head or follow the physician's directive for body position.
Apply elastic stockings to lower extremities. Explanation: To maintain the peripheral circulation in a patient with increased ICP, the nurse must apply elastic stockings to lower extremities. Elastic stockings support the valves of veins in the lower extremities to prevent venous stasis, and relieving pressure promotes the circulation of oxygenated blood through the capillary to peripheral cells and tissues and facilitates venous blood return. The patient's bed should not be jarred or shaken because unexpected physical movement tends to aggravate the pain and does not help in maintaining the peripheral circulation. On the other hand, head elevation helps venous blood and cerebrospinal fluid drain from cerebral areas.
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: naloxone (Narcan). atracurium (Tracrium). nitroglycerin (Nitro-Bid). famotidine (Pepcid).
famotidine (Pepcid). Explanation: Adverse effects of methylprednisolone sodium succinate and other steroids include GI bleeding and wound infection. To help prevent GI bleeding, the physician is likely to order an antacid or a histamine2-receptor antagonist such as famotidine (Pepcid). Naloxone, nitroglycerin, and atracurium aren't used to prevent adverse effects of steroids. Naloxone, an endogenous opioid antagonist, has been studied in animals for its action in inhibiting release of endogenous opioids after spinal cord injury. (Endogenous opioids are thought to contribute to secondary damage to spinal cord tissue by reducing microcirculatory blood flow.) Nitroglycerin is used to dilate the coronary arteries. Atracurium is a nondepolarizing muscle relaxant.
The emergency department nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. The patient is exhibiting an altered level of consciousness. Following a skull X-ray, the patient is diagnosed with a basilar skull fracture. Which sign should alert the nurse to this type of fracture? Battle's sign Babinski sign Brudzinski's sign Kernig's sign
Battle's sign Explanation: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a basilar skull fracture. A positive Kernig's and positive Brudzinski's sign indicate meningeal irritation. Babinski's sign (reflex) is indicative of central nervous system disease in the corticospinal tract.
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: Increased intracranial pressure (ICP) Ischemic cerebrovascular accident (CVA) Decreased intravascular volume Brain tissue necrosis
Explanation The pathological effects of an epidural hematoma are primarily a result of the consequent increase in ICP. Blood loss, ischemia, and necrosis are not the primary sequelae of an epidural hematoma.
Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply. Increased cerebral perfusion Slow bounding pulse Lowered systolic blood pressure Respiratory irregularities Widened pulse pressure
Respiratory irregularities Slow bounding pulse Widened pulse pressure In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure, with a widening of the pulse pressure and cardiac slowing.
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? hypertension increased PaO vasodilation vasoconstriction
vasodilation Explanation: Hypotension and hypoxia lead to vasodilation, which contributes to increased ICP, compressing blood vessels and leading to cerebral ischemia. As ICP continues to rise, autoregulatory mechanisms can become compromised; hypotension and hypoxia lead to vasodilation, which contributes to increased ICP.
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. Tachycardia Nasal congestion Fever Diaphoresis Hypertension
Hypertension Diaphoresis Nasal congestion Explanation: Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the client may be diaphoretic, a fever does not accompany this condition.
The nurse is planning the care of a patient with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply. Anticipating needs and complications Ensuring that the patient regains full brain function Setting priorities for nursing interventions Making nursing assessments Initiating rehabilitation
Making nursing assessments Setting priorities for nursing interventions Anticipating needs and complications Initiating rehabilitation Explanation: The nursing interventions for the patient with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.
The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first? The client with a coup injury The client with an open head injury The client with a concussion The client with a basilar fracture
The client with a basilar fracture Explanation: 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. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.
The client has been brought to the emergency department by their caregiver. The caregiver says that she found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when she came on shift. What are these symptoms indicative of? Contusion Concussion Spinal shock Autonomic dysreflexia
Correct response: Autonomic dysreflexia Explanation: Characteristics of this acute emergency are as follows: Severe hypertension; Slow heart rate; Pounding headache; Nausea; Blurred vision; Flushed skin; Sweating; Goosebumps (erection of pilomotor muscles in the skin); Nasal stuffiness; and Anxiety. The symptoms in the scenario are not symptoms or concussion, spinal shock, or contusion.
When the nurse observes that the patient has extension and external 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? Decorticate Flaccid Normal Decerebrate
Decerebrate Explanation: Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The patient has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the patient has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.
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. Lay the client flat. Notify the physician. Apply antiembolic stockings.
Place the client in a sitting position. Explanation: The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. He or she watches for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.
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 head elevation of 90 degrees to prevent cerebral swelling Supine, with the head of the bed elevated 30 degrees Flat, except for logrolling as needed Flat
Flat, except for logrolling as needed Explanation: When caring for the client with a possible cervical spinal injury who's wearing a cervical collar, the nurse must keep the client flat to decrease mobilization and prevent further injury to the spinal column. The client can be logrolled, if necessary, with the cervical collar on.
A nurse is providing care to a client diagnosed with a spinal cord tumor. Based on the nurse's understanding about treatment for this type of tumor, the nurse would most likely expect to develop a teaching plan related to which therapy? Chemotherapy Surgery Spinal cord decompression Radiation therapy
Surgery Explanation: Treatment of spinal cord tumors depends on the type, location of the tumor, the presenting symptoms, and physical status of the client. Surgical intervention, if appropriate, is the primary treatment for most tumors. Other treatment modalities include partial removal of the tumor with decompression of the spinal cord. For metastatic lesions of the spine, radiation therapy can be used to decrease the size of the tumor. Chemotherapy options are limited due to the blood-brain barrier.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. The client's level of consciousness has improved. The client prefers to rest in the semi-Fowler's position. The client has periorbital edema and ecchymosis.
The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. Explanation: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.
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 client to contact the physician or return to the ED if the client demonstrates reports which complications? Select all that apply. Vomiting Weakness on one side of the body Slurred speech Sleeps for short periods of time Headache
Vomiting Weakness on one side of the body Slurred speech Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately.
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 Decerebrate Rigid Decorticate
Flaccid Explanation: LOC, a sensitive indicator of neurologic function, is assessed based on the criteria in the Glasgow Coma Scale: eye opening, verbal response, and motor response (Barlow, 2012). The patient's responses are rated on a scale from 3 to 15. A score of 3 indicates severe impairment of neurologic function, brain death, or pharmacologic inhibition of the neurologic response. A score of 15 indicates that the patient is fully responsive (see Chapter 68). An inappropriate or nonpurposeful response is random and aimless. Posturing may be decorticate or decerebrate (Fig. 66-1; see also Chapter 65). The most severe neurologic impairment results in flaccidity. The motor response cannot be elicited or assessed when the patient has been administered pharmacologic paralyzing agents (i.e., neuromuscular blocking agents).
Which signs are considered cardinal signs of brain death? Select all that apply. Absence of brainstem reflexes Coma No brain waves Apnea
Absence of brainstem reflexes Apnea Coma Explanation: The three cardinal signs of brain death on clinical examination are coma, the absence of brainstem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brainstem auditory-evoked potential, are often used to confirm brain death.
A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention? Urine output of 100 mL/hr Cool, dry skin Capillary refill of 2 seconds Shivering
Shivering Explanation: Shivering can increase intracranial pressure by increasing vasoconstriction and circulating catecholamines. Shivering also increases oxygen consumption. A capillary refill of 2 seconds, urine output of 100mL/hr, and cool, dry skin are expected findings.
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: use a condom catheter instead of an invasive one. place the client on fluid restrictions. increase the frequency of the catheterizations. insert an indwelling urinary catheter.
increase the frequency of the catheterizations. Explanation: As a rule of practice, if intermittent catheterization for urine retention typically yields 500 ml or more, the frequency of catheterization should be increased. Indwelling catheterization is less preferred because of the risk of urinary tract infection and the loss of bladder tone. Fluid restrictions aren't indicated in this case; the problem isn't overhydration, rather it's urine retention. A condom catheter doesn't help empty the bladder of the client with urine retention.
The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply. Older adult Low-income community Substance abuse Male gender Young age
Young age Male gender Substance abuse The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.
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? Provide ventriculostomy care. Administer acetaminophen per orders. Inspect the ICP monitor to ensure it is working properly. Assess for signs and symptoms of infection.
Administer acetaminophen per orders. Explanation: The nurse needs to control the fever by administering the ordered acetaminophen as the priority action. An increase in the client's temperature can lead to increased cerebral metabolic demands and poor outcomes if not properly treated. The nurse should always inspect the equipment to ensure that it is working properly, but this is not the priority because there is no indication of equipment failure. The nurse should provide ventriculostomy care, but this is not the priority as there is an elevated temperature. Because the client has an elevated temperature, the nurse should assess for signs and symptoms of infection, but only after treating the elevated temperature.
Which interventions are appropriate for a client with increased intracranial pressure (ICP)? Select all that apply. Encouraging deep breathing and coughing every 2 hours Maintaining aseptic technique with an intraventricular catheter Frequent oral care Administering prescribed antipyretics Elevating the head of the bed to 90 degrees
Administering prescribed antipyretics Maintaining aseptic technique with an intraventricular catheter Frequent oral care Explanation: Controlling fever is an important intervention for a client with increased ICP because fevers can cause an increase in cerebral metabolism and can lead to cerebral edema. Antipyretics are appropriate to control a fever. It is imperative that the nurse use aseptic technique when caring for the intraventricular catheter because of its risk for infection. Oral care should be provided frequently because the client is likely to be placed on a fluid restriction and will have dry mucous membranes. A nondrying oral rinse may be used. Coughing should be discouraged in a client with increased ICP because it increases intrathoracic pressure, and thus ICP. Unless contraindicated, the head of the bed should be elevated to 30 to 45 degrees and in a neutral position to allow for venous drainage.
The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing's reflex? Select all that apply. Apical pulse is 42 beats per minute Systolic blood pressure is 180 mm/Hg Blood pressure is 140/38 mmHg Weakness on one side of the body Urine output over 100 mL/hr
Apical pulse is 42 beats per minute Blood pressure is 140/38 mmHg Systolic blood pressure is 180 mm/Hg Explanation: Signs of increasing intracranial pressure and Cushing's reflex include bradycardia, widening pulse pressure, elevated systolic blood pressure, and irregular respirations. Badycardia is a heart or apical rate below 50. A widening pulse pressure is typically defined as a large or wide difference between the two blood pressure readings (systolic and diastolic pressure). Widening pulse pressure readings are present when the difference is greater than 60. In this instance the difference between 140 and 38 is 102. Elevated systolic blood pressure and/or hypertension generally have readings above 140 mm/Hg. Urine output is not an indicator for Cushing's reflex. Weakness on one side of the body or hemiparesis is a finding associated with a stroke.
The nurse is caring for a male client who has emerged from a coma following a head injury. The client is agitated. Which intervention will the nurse implement to prevent injury to the client? Provide a dimly lit room Turn and reposition the client every 2 hours Administer opioids to the client Apply an external urinary sheath catheter
Apply an external urinary sheath catheter Explanation: A strategy the nurse can implement to prevent client injury is to use an external sheath catheter for a male client if incontinence occurs. Because prolonged use of an indwelling catheter inevitably produces infection, the client may be placed on an intermittent catheterization schedule. Opioids are contraindicated because they depress respirations, constrict the pupils, and alter responsiveness. Providing adequate lighting to prevent visual hallucinations is recommended. Repositioning the client every 2 hours maintains skin integrity.
A patient with spinal cord injury has a nursing diagnosis of altered mobility. Which of the following would be included as an appropriate nursing intervention to prevent deep vein thrombosis (DVT) from occurring? Applying thigh-high elastic stockings Administering an antifibrinolytic agent Placing the patient on a fluid restriction Assisting the patient with passive range of motion exercises
Applying thigh-high elastic stockings Explanation: It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT. The patient should not be placed on fluid restriction because a dehydrated state will increase the risk of clotting throughout the body. Antifibrinolytic agents cause the blood to clot, which is absolutely contraindicated in this situation.
A patient who suffered a T6 lesion during a spinal cord injury (SCI) 10 days ago is progressing with treatment and rehabilitation following the immediate treatment of his injury. When preparing to help the physical therapist mobilize the patient for the first time since the injury, the nurse should prioritize which of the following assessments? Monitoring the patient's pain level Assessing the patient's respiratory rate Assessing the patient's blood pressure Monitoring the patient's cognition
Assessing the patient's blood pressure Explanation: For the first 2 weeks following SCI, blood pressure tends to be unstable and quite low. It gradually returns to preinjury levels, but periodic episodes of severe orthostatic hypotension frequently interfere with efforts to mobilize the patient. Close monitoring of vital signs before and during position changes is essential. The other listed assessments should be addressed but they are less closely related to the specific risks associated with this procedure at this point in the patient's recovery.
A nurse caring for a patient with head trauma will be monitoring the patient for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply. Tachycardia Bradycardia Hypertension Pupillary constriction Bradypnea
Bradycardia Bradypnea Hypertension Explanation: At a certain point as intracranial pressure increases due to an injury, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. When this occurs, the patient exhibits significant changes in mental status and vital signs. The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing's triad, which is a grave sign.
A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC? By assessing according to the Glasgow Coma Scale (GCS) By engaging the patient in a conversation, if possible By eliciting the patient's response to a question requiring judgment By observing the patient's interactions with caregivers
By assessing according to the Glasgow Coma Scale (GCS) Explanation: The GCS provides a valid, reliable, and objective indication of LOC. As such, it is superior to other assessment techniques such as asking the patient to respond to a scenario, conducting a conversation, or passively observing his or her interactions.
When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred? L1 T6 C3 C5
C5 Explanation: The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.
The Monro-Kellie hypothesis refers to which of the following? The dynamic equilibrium of cranial contents The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure Unresponsiveness to the environment A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function
Correct response: The dynamic equilibrium of cranial contents Explanation: The hypothesis states that because of the limited space for expansion within the skull, an increase in any one of the cranial contents (brain tissue, blood, or cerebrospinal fluid) causes a change in the volume of the others. Akinetic mutism is the phrase used to refer to unresponsiveness to the environment. Cushing's response is the phrase used to refer to the brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure. Persistent vegetative state is the phrase used to describe a condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function.
The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders? The second cervical vertebrae The first thoracic vertebrae The first lumbar vertebrae The seventh thoracic vertebrae
Correct response: The first thoracic vertebrae Explanation: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.
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? Insertion of an intracranial (IC) monitoring device Emergency craniotomy Treatment with antihypertensives Administration of anticoagulant therapy
Emergency craniotomy Explanation: An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Antihypertensive medications would not be a priority. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed because this could further increase bleeding activity. Insertion of an IC monitoring device may be done during the surgery, but is not the immediate priority for this patient.
A client with a spinal cord injury says he has difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury? Burning sensation on urination Fever and change in urine clarity Frequency of urination Lower back pain
Fever and change in urine clarity Explanation: Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.
A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? Look for a halo sign Have the client avoid physical exertion Emphasize complete bed rest Look for signs of increased intracranial pressure
Look for signs of increased intracranial pressure Explanation: The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.
A client with a spinal cord injury develops an excruciating headache and profuse diuresis. Which action will the nurse take first? Palpate the bladder for distention. Examine the rectum for a fecal mass. Asses the skin for areas of pressure. Place in a seated position.
Place in a seated position. Explanation: Autonomic dysreflexia, also known as autonomic hyperreflexia, is an acute life-threatening emergency that occurs as a result of exaggerated autonomic responses to stimuli that are harmless in people without spinal cord injury (SCI). It occurs only after spinal shock has resolved. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia. The first action to take is to place the client in a seated position to lower the blood pressure. Next, the bladder can be assessed for distention, the skin assessed for areas of pressure, and the rectum assessed for a fecal mass, which can all be the reasons for the onset of the symptoms.
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 Pulse and blood pressure Respiratory pattern Numbness and tingling
Pulse and blood pressure Explanation: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.
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? Turning frame Traction with weights and pulleys Cast Cervical collar
Traction with weights and pulleys Explanation: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
