Brunner Chapter 68 Neurologic Trauma Questions – Flashcards
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ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?
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Bruising over the mastoid
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A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1½ hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure
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Risk for injury If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patient's neck, which can result in extension of a cervical injury.
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A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?
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Bradycardia and hypertension It occurs in cord lesions above T6 after spinal shock has resolved
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A nurse is caring for a patient with ICP caused by a traumatic brain injury. The following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?
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Hyperthermia It increases the metabolic demands of the brain and may indicate brain stem damage. Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable.
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A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when patient fell she was "knocked out," but came to and "seemed okay." Now she is complaining of a severe headache not feeling well. The team suspects epidural hematoma, prompting nurse to prepare for what priority intervention?
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Emergency craniotomy 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.
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A patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, the nurse's most appropriate action includes?
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Prepare for interventions to increase the patient's BP. Manifestations of neurogenic shock include decreased BP and heart rate.
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An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
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Motor vehicle accidents
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A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?
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Applying thigh-high elastic stockings
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Paramedics have brought an intubated patient to the ED following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. An appropriate nursing interventions would include which of the following?
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Administer benzodiazepines on a PRN basis.
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Patient who has sustained a non-depressed skull fracture is admitted to the acute medical unit. Nurse should include the following?
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Watchful waiting and close monitoring
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Patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. The patient's current health status is most likely to have precipitated this event?
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Patient's urinary catheter became occluded. A distended bladder is the most common cause of autonomic dysreflexia
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Patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patient's care plan, the nurse specifies that contractures can best be prevented by what action?
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Initiating (ROM) exercises as soon as possible after the injury
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A patient with a head injury has been increasingly agitated and the nurse has consequently identified at risk for injury. What is the nurse's best intervention for preventing injury?
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Pad the side rails of the patient's bed.
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A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache. What should the nurse do first?
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Check the patient's indwelling urinary catheter for kinks to ensure patency.
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A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient, the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
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Spinal shock. In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur.
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An elderly woman found with a head injury on the floor of her home is subsequently admitted to the neurologic ICU. What is the best rationale for the following physician orders: elevate the HOB; keep the head in neutral alignment with no neck flexion or head rotation; avoid sharp hip flexion?
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To avoid impeding venous outflow which increases ICP
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A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?
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Absence of reflexes along with flaccid extremities. During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinski's reflex, hyperreflexia, and spasticity of all four extremities.
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A nurse is reviewing the trend of a patient's scores on the Glasgow Coma Scale . This allows the nurse to gauge what aspect of the patient's status Level of consciousness?
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The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.
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A nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death?
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Apnea, Coma, Absence of brain stem reflexes
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Following a spinal cord injury a patient is placed in halo traction. While performing pin site care, the nurse notes that one of the traction pins has become detached. The nurse would be correct in implementing what priority nursing action?
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Notify the neurosurgeon of the occurrence.
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ED is notified that a 6-year-old is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are acceptable. What is the the primary goal of initial therapy?
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Preserving brain homeostasis and preventing secondary brain injury
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A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. The primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure is?
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CT and MRI (It is not a PET scan, which shows brain function, not brain structure.)
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13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. The child regains consciousness. 5 hours after being admitted, he can't remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?
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Grade 3 concussion with temporal lobe involvement. In a grade 3 concussion there is a loss of consciousness lasting from seconds to minutes. Temporal lobe involvement results in amnesia. Frontal lobe involvement can cause uncharacteristic behavior and a grade 1 concussion doesn't involve loss of consciousness. duration of unconsciousness is an indicator of the severity of the concussion.
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An 82-year-old man is admitted for observation after a fall. Due to his age, nurse knows that the patient is at increased risk for what complication of his injury?
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Hematoma. 2 factors place older adults at increased risk for hematomas. The dura becomes more adherent to the skull with increasing age. aspirin and anticoagulants as part of routine management
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Neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. When should nurse begin to use a neurologic flow chart?
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As soon as the initial assessment is made
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The nurse planning the care of a patient with head injuries is addressing the patient's nursing diagnosis of "sleep deprivation." What action should the nurse implement?
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Cluster overnight nursing activities to minimize disturbances.
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The nurse has implemented interventions aimed at facilitating family coping in the care of a patient with a traumatic brain injury. How can the nurse best facilitate family coping?
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Assist the family in setting appropriate short-term goals.
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The school nurse is giving a presentation on preventing spinal cord injuries . What should the nurse identify as prominent risk factors for SCI? (Select all that apply)
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-Young age -Male gender -Alcohol & drug use
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The school nurse has been called to the football field where player is immobile on the field after landing awkwardly on his head during a play. While awaiting an ambulance, what action should the nurse perform?
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Ensure that the player is not moved.
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The nurse is caring for a patient whose spinal cord injury has caused recent muscle spasticity. What medication should the nurse expect to be ordered to control this?
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Baclofen (Lioresal) Baclofen is classified as an antispasmodic agent in the treatment of muscles spasms related to spinal cord injury.
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The nurse is planning the care of a patient with a T1 spinal cord injury. The nurse has identified the diagnosis of "risk for impaired skin integrity. The nurse can best address this risk by?
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Change the patient's position frequently.
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A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patient's risk for orthostatic hypotension?
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Monitor the patient's BP before and during position changes.
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The nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of C4. When planning the patient's care, what aspect of the patient's neurologic and functional status should the nurse consider?
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The patient will require full assistance for all aspects of elimination.
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The nurse is providing health education to a patient who has a C6 spinal cord injury. The patient asks why autonomic dysreflexia is considered an emergency?
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The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel or lead to increased ICP.
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The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. The most appropriate nursing action would be?
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Increase the frequency of ROM exercises.
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Splints are ordered for a patient who is at risk of developing footdrop following a spinal cord injury. The nurse caring for this patient knows that the splints are removed and reapplied when?
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Every 2 hours
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A patient who is being treated in the hospital for a spinal cord injury is advocating for the removal of his urinary catheter, stating that he wants to try to resume normal elimination. What principle should guide the care team's decision regarding this intervention?
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Urinary retention can have serious consequences in patients with SCIs.
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A patient with spinal cord injury is ready to be discharged home. A family member asks the nurse to review potential complications one more time. (Select all that apply)
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-Orthostatic hypotension -Autonomic dysreflexia -DVT
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The nurse recognizes that a patient with a SCI is at risk for muscle spasticity. How can the nurse best prevent this complication of an SCI?
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Perform passive ROM exercises as ordered.
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A patient is admitted to the neurologic ICU with a C4 spinal cord injury. When writing the plan of care for this patient, the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?
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Ineffective breathing patterns related to weakness of the intercostal muscles. A nursing diagnosis related to breathing pattern would be the priority for this patient. A C4 spinal cord injury will require ventilatory support, due to the diaphragm and intercostals being affected.
