Saunders Practice Brain Injury and SCI

The nurse has completed discharge instructions for a client with application of a halo device who sustained a cervical spinal cord injury. Which statement indicates that the client needs further clarification of the instructions? "I will use a straw for drinking." "I will drive only during the daytime." "I will be careful because the device alters balance." I will wash the skin daily under the lamb's wool liner of the vest."

"I will drive only during the daytime." The client cannot drive at all, because the device impairs the range of vision.

A client with a history of spinal cord injury is beginning medication therapy with baclofen. The nurse determines that the client understands the side/adverse effects of the medication if the client makes which statement? "The medication may make me drowsy." "The medication can cause high blood pressure." "The medication may cause me to have some muscle pain." "The medication may increase my sensitivity to bright light."

"The medication may make me drowsy."

The home care nurse is making extended follow-up visits to a client discharged from the hospital after a moderately severe head injury. The family states that the client is behaving differently than before the accident. The client is more fatigued and irritable and has some memory problems. The client, who was previously very even tempered, is prone to outbursts of temper now. The nurse determines that these behaviors are indicative of which problem? Intracranial pressure changes A long-term sequela of the injury A worsening of the original injury A short-term problem that will resolve in about 1 month

A long-term sequela of the injury

The nurse is conducting home visits with a head-injured client with residual cognitive deficits. The client has problems with memory, has a shortened attention span, is easily distracted, and processes information slowly. The nurse plans to talk with the primary health care provider about referring the client to which professional? A psychologist A social worker A neuropsychologist A vocational rehabilitation specialist

A neuropsychologist

Dantrolene sodium has been administered to a client with a spinal cord injury. The nurse determines that the client is experiencing a side or adverse effect of the medication if which is noted? Dizziness Drowsiness Abdominal pain Lightheadedness

Abdominal pain Dantrium is hepatotoxic. The nurse observes for indications of liver dysfunction, which include jaundice, abdominal pain, and malaise.

A client with a spinal cord injury becomes angry and belligerent whenever the nurse tries to administer care. The nurse should perform which action? Ask the family to deliver the care. Leave the client alone until ready to participate. Advise the client that rehabilitation progresses more quickly with cooperation. Acknowledge the client's anger and continue to encourage participation in care.

Acknowledge the client's anger and continue to encourage participation in care.

The family of a client with a spinal cord injury rushes to the nursing station, saying that the client needs immediate help. On entering the room, the nurse notes that the client is diaphoretic with a flushed face and neck and is complaining of a severe headache. The pulse rate is 40 beats/minute, and the blood pressure is 230/100 mm Hg. The nurse acts quickly, suspecting that the client is experiencing which condition? Spinal shock Pulmonary embolism Autonomic dysreflexia Malignant hyperthermia

Autonomic dysreflexia

A client who has a spinal cord injury that resulted in paraplegia experiences a sudden onset of severe headache and nausea. The client is diaphoretic with piloerection and has flushing of the skin. The client's systolic blood pressure (BP) is 210 mm Hg. What should the nurse immediately suspect? Return of spinal shock Malignant hypertension Impending brain attack (stroke) Autonomic dysreflexia (hyperreflexia)

Autonomic dysreflexia (hyperreflexia)

The nurse in the neurological unit is monitoring a client with a head injury for signs of increased intracranial pressure (ICP). The nurse reviews the assessment findings for the client and notes documentation of the presence of Cushing's reflex. The nurse determines that the presence of this reflex is obtained by assessing which item?

Blood pressure Cushing's reflex is a late sign of increased ICP and consists of a widening pulse pressure (systolic pressure rises faster than diastolic pressure) and bradycardia. The remaining options are unrelated to monitoring for Cushing's reflex.

The nurse in the neurological unit is caring for a client who was in a motor vehicle crash and sustained a blunt head injury. On assessment of the client, the nurse notes the presence of bloody drainage from the nose. Which nursing action is most appropriate? Insert nasal packing. Document the findings. Contact the primary health care provider (PHCP). Monitor the client's blood pressure and check for signs of increased intracranial pressure.

Contact the primary health care provider (PHCP).

The client with a traumatic brain injury (TBI) has begun excreting copious amounts of dilute urine through the Foley catheter. The client's urine output for the previous shift was 3000 mL. The nurse expects that the primary health care provider will prescribe which medication? Mannitol Desmopressin Ethacrynic acid Dexamethasone

Desmopressin

The nurse is assessing a client with a brainstem injury. In addition to obtaining the client's vital signs and determining the Glasgow Coma Scale score, what priority intervention should the nurse plan to implement? Check cranial nerve functioning. Determine the cause of the accident. Draw blood for arterial blood gas analysis. Perform a pulmonary wedge pressure measurement

Draw blood for arterial blood gas analysis. Assessment should be specific to the area of the brain involved. The respiratory center is located in the brainstem. Assessing the respiratory status is the priority for a client with a brainstem injury.

The nurse is caring for a client who sustained a spinal cord injury. During administration of morning care, the client begins to exhibit signs and symptoms of autonomic dysreflexia. Which initial nursing action should the nurse take? Elevate the head of the bed. Examine the rectum digitally. Assess the client's blood pressure. Place the client in the prone position.

Elevate the head of the bed.

Dantrolene is prescribed for a client with spinal cord injury for discomfort caused by spasticity. Which finding would alert the nurse to a potential adverse effect associated with this medication? Headache Blurred vision Elevated temperature Abdominal distention

Elevated temperature

The nurse is caring for a client in the emergency department who has sustained 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 that this sequence is compatible with which most likely condition? Concussion Skull fracture Subdural hematoma Epidural hematoma

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

A client recovering from a head injury is participating in care. The nurse determines that the client understands measures to prevent elevations in intracranial pressure if the nurse observes the client doing which activity? Blowing the nose Isometric exercises Coughing vigorously Exhaling during repositioning

Exhaling during repositioning

The nurse is evaluating the neurological signs of a client in spinal shock following spinal cord injury. Which observation indicates that spinal shock persists? Hyperreflexia Positive reflexes Flaccid paralysis Reflex emptying of the bladder

Flaccid paralysis

A client has clear fluid leaking from the nose following a basilar skull fracture. Which finding would alert the nurse that cerebrospinal fluid is present? Fluid is clear and tests negative for glucose. Fluid is grossly bloody in appearance and has a pH of 6. Fluid clumps together on the dressing and has a pH of 7. Fluid separates into concentric rings and tests positive for glucose.

Fluid separates into concentric rings and tests positive for glucose.

The client with a head injury opens eyes to sound, has no verbal response, and localizes to painful stimuli when applied to each extremity. How should the nurse document the Glasgow Coma Scale (GCS) score? GCS = 3 GCS = 6 GCS = 9 GCS = 11

GCS = 9

A client has a closed head injury with increased intracranial pressure (ICP). The increased ICP is being managed by mannitol 25 g by the intravenous (IV) route every 2 hours. The nurse is planning to administer this medication via IV pump in what manner? Mixed in solution with the IV antibiotics Giving it slowly over 30 to 90 minutes Piggybacked into the packed red blood cells Giving it rapidly over 5 minutes by IV bolus

Giving it slowly over 30 to 90 minutes

A client with a traumatic closed head injury shows signs of secondary brain injury. What are some manifestations of secondary brain injury? Select all that apply. Fever Seizures Hypoxia Ischemia Hypotension Increased intracranial pressure (ICP)

Hypoxia Ischemia Hypotension Increased intracranial pressure (ICP) Secondary brain injury can occur several hours to days after the initial brain injury and is a major concern when managing brain trauma. Nursing management of the client with an acute intracranial problem must include management of secondary injury. Manifestations of secondary injury include hypoxia, ischemia, hypotension, and increased ICP that follows primary injury.

The nurse is caring for the client with increased intracranial pressure as a result of a head injury? The nurse would note which trend in vital signs if the intracranial pressure is rising? Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure

Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure

The home care nurse is making a visit to a client who requires use of a wheelchair after a spinal cord injury sustained 4 months earlier. Just before leaving the home, the nurse ensures that which intervention has been done to prevent an episode of autonomic dysreflexia (hyperreflexia)? Updating the home safety sheet Leaving the client in an unchilled area of the room Noting a bowel movement on the client progress note Recording the amount of urine obtained with catheterization

Leaving the client in an unchilled area of the room The most common cause of autonomic dysreflexia is visceral stimuli, such as with blockage of urinary drainage or with constipation. Barring these, other causes include noxious mechanical and thermal stimuli, particularly pressure and overchilling.

A client admitted to the nursing unit from the hospital emergency department has a C4 spinal cord injury. In conducting the admission assessment, what is the nurse's priority action? Take the temperature. Listen to breath sounds. Observe for dyskinesias. Assess extremity muscle strength.

Listen to breath sounds.

A client experiencing spasticity as a result of spinal cord injury has a new prescription for dantrolene. Before administering the first dose, the nurse checks to see if which baseline study has been done? Liver function studies Renal function studies Otoscopic examination Blood glucose measurements

Liver function studies

A client with a spinal cord injury expresses little interest in food and is very particular about the choice of meals that are actually eaten. How should the nurse interpret this information? Anorexia is a sign of clinical depression, and a referral to a psychologist is needed. The client has compulsive habits that should be ignored as long as they are not harmful. The client probably has a naturally slow metabolism, and the decreased nutritional intake will not matter. Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

Meal choices represent an area of client control and should be encouraged as much as is nutritionally reasonable.

A client was seen and treated in the hospital emergency department for a concussion. The nurse determines that family members need further teaching if they verbalize to call the primary health care provider (PHCP) for which client sign or symptom? Vomiting Minor headache Difficulty speaking Difficulty awakening

Minor headache

The nurse is assessing the motor and sensory function of an unconscious client who sustained a head injury. The nurse should use which technique to test the client's peripheral response to pain? Sternal rub Nailbed pressure Pressure on the orbital rim Squeezing of the sternocleidomastoid muscle

Nailbed pressure

The nurse is caring for a client who is brought to the hospital emergency department with a spinal cord injury. The nurse minimizes the risk of compounding the injury by performing which action? Keeping the client on a stretcher Logrolling the client onto a soft mattress Logrolling the client onto a firm mattress Placing the client on a bed that provides spinal immobilization

Placing the client on a bed that provides spinal immobilization

The nurse has a prescription to give dexamethasone by the intravenous (IV) route to a client with cerebral edema. How should the nurse prepare this medication? Diluting the medication in 500 mL of 5% dextrose Preparing an undiluted direct injection of the medication Diluting the medication in 1 mL of lactated Ringer's solution for direct injection Diluting the medication in 10% dextrose in water and administering it as a direct injection

Preparing an undiluted direct injection of the medication

The client with a head injury is experiencing signs of increased intracranial pressure (ICP), and mannitol is prescribed. The nurse administering this medication expects which as intended effects of this medication? Select all that apply. Reduced ICP Increased diuresis Increased osmotic pressure of glomerular filtrate Reduced tubular reabsorption of water and solutes Reabsorption of sodium and water in the loop of Henle

Reduced ICP Increased diuresis Increased osmotic pressure of glomerular filtrate Reduced tubular reabsorption of water and solutes

The nurse is caring for a client with spinal cord injury (SCI) who is participating in a bowel retraining program. What should the nurse anticipate to promote during the bowel retraining program? Sufficiently low water content in the stool Low intestinal roughage that promotes easier digestion Constriction of the anal sphincter based on voluntary control Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

Stimulation of the parasympathetic reflex center at the S1 to S4 level in the spinal cord

The nurse is caring for a client with a head injury. The client's intracranial pressure reading is 8 mm Hg. Which condition should the nurse document? The intracranial pressure reading is normal. The intracranial pressure reading is elevated. The intracranial pressure reading is borderline. An intracranial pressure reading of 8 mm Hg is low.

The intracranial pressure reading is normal.

A client with a probable minor head injury resulting from a motor vehicle crash is admitted to the hospital for observation. The nurse leaves the cervical collar applied to the client in place until when? The family comes to visit. The nurse needs to do physical care. The primary health care provider makes rounds. The results of spinal radiography are known.

The results of spinal radiography are known.

A client is brought to the emergency department by emergency medical services (EMS) after being hit by a car. The name of the client is unknown, and the client has sustained a severe head injury and multiple fractures and is unconscious. An emergency craniotomy is required. Regarding informed consent for the surgical procedure, which is the best action? Obtain a court order for the surgical procedure. Ask the EMS team to sign the informed consent. Transport the victim to the operating room for surgery. Call the police to identify the client and locate the family.

Transport the victim to the operating room for surgery. In general, there are two situations in which informed consent of an adult client is not needed. One is when an emergency is present and delaying treatment for the purpose of obtaining informed consent would result in injury or death to the client. The second is when the client waives the right to give informed consent.

The nurse has just admitted to the nursing unit a client with a basilar skull fracture who is at risk for increased intracranial pressure. Pending specific primary health care provider prescriptions, the nurse should safely place the client in which positions? Select all that apply. Head midline Neck in neutral position Head of bed elevated 30 to 45 degrees Head turned to the side when flat in bed Neck and jaw flexed forward when opening the mouth

ead midline Neck in neutral position Head of bed elevated 30 to 45 degrees

A client who suffered a severe head injury has had vigorous treatment to control cerebral edema. Brain death has been determined. The nurse prepares to carry out which measure to maintain viability of the kidneys before organ donation? Assessing lung sounds Monitoring temperature Administering intravenous (IV) fluids Performing range-of-motion exercises to the extremities

Administering intravenous (IV) fluids

A client with a spinal cord injury at the level of C5 has a weakened respiratory effort and ineffective cough and is using accessory neck muscles in breathing. The nurse carefully monitors the client and suspects the presence of which problem? Altered breathing pattern Increased likelihood of injury Ineffective oxygen consumption Increased susceptibility to aspiration

Altered breathing pattern

A postoperative craniotomy client who sustained a severe head injury is admitted to the neurological unit. What nursing intervention is necessary for this client? Take and record vital signs every 4 to 8 hours. Prophylactically hyperventilate during the first 24 hours. Treat a central fever with the administration of antipyretic medications such as acetaminophen. Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

Keep the head of the bed elevated at least 30 degrees, and position the client to avoid extreme flexion or extension of the neck and head.

A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse should include which measures in the plan of care to minimize the risk of occurrence? Select all that apply. Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Limiting bladder catheterization to once every 12 hours Turning and repositioning the client at least every 2 hours Ensuring that the client has a bowel movement at least once a week

Keeping the linens wrinkle-free under the client Preventing unnecessary pressure on the lower limbs Turning and repositioning the client at least every 2 hours