PUCH63 NEUROLOGIC TRAUMA PART III
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? A. Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. B. Contusions are deep brain injuries. C. Contusions are microscopic brain injuries. D. Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.
A
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? A. client maintains mechanical ventilation with minimal mucus accumulation B. client reports no discomfort C. client's skin remains clean, dry, and intact D. client regains bowel elimination capacity
A
A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? A. acute B. chronic C. subacute D. intracerebral
A
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? A. Place the client in a sitting position. B. Lay the client flat. C. Apply antiembolic stockings. D. Notify the physician.
A
A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A physician has intubated the client and written orders to wean him from sedation therapy. A nurse needs further assessment data to determine whether: A. she'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube. B. nutritional protocol will be effective after the client sedation therapy is tapered. C. to continue IV administration of other scheduled medications. D. payment status will change if the client isn't sedated.
A
The Monro-Kellie hypothesis refers to which of the following? A. The dynamic equilibrium of cranial contents B. Unresponsiveness to the environment C. The brain's attempt to restore blood flow by increasing arterial pressure to overcome the increased intracranial pressure D. A condition in which the patient is wakeful but devoid of conscious content, without cognitive or affective mental function
A
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? A. Insertion of a nasogastric tube B. A large volume enema C. Digital stimulation D. Bowel surgery
A
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A. The client has cerebral spinal fluid (CSF) leaking from the ear. B. The client has ecchymosis in the periorbital region. C. The client has an elevated temperature. D. The client has serous drainage from the nose.
A
Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure? A. Herniation B. Autoregulation C. Cushing's response D. Monro-Kellie hypothesis
A
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. A. Eye opening B. Verbal response C. Motor response D. Intelligence E. Muscle strength
A B C
Which activities would the client with a T4 spinal cord injury be able to perform independently? Select all that apply. A. Eating B. Breathing C. Ambulating D. Transferring to a wheelchair E. Writing
A B D E
Which of the following are the immediate complications of spinal cord injury? A. Respiratory arrest B. Tetraplegia C. Spinal shock D. Paraplegia E. Autonomic dysreflexia
A C
The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply. A. Absence of brainstem reflexes B. No brain waves C. Apnea D. Coma
A C D
Pressure ulcers may begin within hours of an acute spinal cord injury (SCI) and may cause delay of rehabilitation, adding to the cost of hospitalization. The most effective approach is prevention. Which of the following nursing interventions will most protect the client against pressure ulcers? A. Continuous use of an indwelling catheter B. Meticulous cleanliness C. Avoidance of all lotions and lubricants D. Allowing the client to choose the position of comfort
B
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? A. Concussion B. Autonomic dysreflexia C. Spinal shock D. Contusion
B
When planning care for a client with a head injury, which position should the nurse include in the care plan to enhance client outcomes? A. Trendelenburg's B. 30-degree head elevation C. Flat D. Side-lying
B
Which type of brain injury is characterized by a loss of consciousness associated with stupor and confusion? A. Concussion B. Contusion C. Diffuse axonal injury D. Intracranial hemorrhage
B
The nurse is concerned that a client with a traumatic brain injury is developing an endocrine disorder. Which assessment will the nurse complete for this client? Select all that apply. A. Hemoglobin B. Blood glucose C. Urine acetone D. Intake and output E. Serum electrolytes
B C D E
A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and his family? A. Slight headache B. Rapid heart rate C. Sweating D. Runny nose
C
A nurse completes the Glasgow Coma Scale on a patient with traumatic brain injury (TBI). Her assessment results in a score of 6, which is interpreted as: A. Mild TBI. B. Moderate TBI. C. Severe TBI. D. Brain death.
C
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? A. Cervical collar B. Cast C. Traction with weights and pulleys D. Turning frame
C
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? A. Disturbed sensory perception (visual) related to neurologic trauma B. Feeding self-care deficit related to neurologic trauma C. Impaired verbal communication related to confusion D. Risk for injury related to neurologic deficit
D
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? A. Disturbed sensory perception (visual) B. Dressing or grooming self-care deficit C. Impaired verbal communication D. Risk for injury
D
A client is admitted to the hospital after sustaining a closed head injury in a skiing accident. The physician ordered neurologic assessments to be performed every 2 hours. The client's neurologic assessments have been unchanged since admission, and the client is complaining of a headache. Which intervention by the nurse is best? A. Administer codeine 30 mg by mouth as ordered and continue neurologic assessments as ordered. B. Assess the client's neurologic status for subtle changes, administer acetaminophen, and then reassess the client in 30 minutes. C. Reassure the client that a headache is expected and will go away without treatment. D. Notify the physician; a headache is an early sign of worsening neurologic status.
B
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. Flat B. Supine, with the head of the bed elevated 30 degrees C. Flat, except for logrolling as needed D. A head elevation of 90 degrees to prevent cerebral swelling
C
Which signs are considered cardinal signs of brain death? Select all that apply. A. Absence of brainstem reflexes B. No brain waves C. Apnea D. Coma
A C D
