Deck 67: Management of Patients With Neurologic Trauma

Question 1

The 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?

A) Epistaxis
B) Periorbital edema
C) Bruising over the mastoid
D) Unilateral facial numbness

Answer 1

Bruising over the mastoid

Question 2

A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 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?

A) Risk for impaired skin integrity
B) Risk for injury
C) Risk for autonomic dysreflexia
D) Risk for suffocation

Answer 2

Risk for injury

Question 3

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

A) Respiratory distress and projectile vomiting
B) Bradycardia and hypertension
C) Tachycardia and agitation
D) Third-spacing and hyperthermia

Answer 3

Bradycardia and hypertension

Question 4

The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a traumatic brain injury. Which of the following clinical manifestations would suggest that the patient may be experiencing increased brain compression causing brain stem damage?

A) Hyperthermia
B) Tachycardia
C) Hypertension
D) Bradypnea

Question 5

A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

A) Insertion of an intracranial monitoring device
B) Treatment with antihypertensives
C) Emergency craniotomy
D) Administration of anticoagulant therapy

Question 6

The staff educator is precepting a nurse new to the critical care unit when 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, what would be the nurses most appropriate action?

A) Prepare to transfuse packed red blood cells.
B) Prepare for interventions to increase the patients BP.
C) Place the patient in the Trendelenberg position.
D) Prepare an ice bath to lower core body temperature.

Question 7

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?

A) Sports-related injuries
B) Acts of violence
C) Injuries due to a fall
D) Motor vehicle accidents

Question 8

A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

A) Placing the patient on a fluid restriction as ordered
B) Applying thigh-high elastic stockings
C) Administering an antifibrinolyic agent
D) Assisting the patient with passive range of motion (PROM) exercises

Question 9

Paramedics have brought an intubated patient to the RD following a head injury due to accelerationdeceleration motor vehicle accident. Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

A) Keep the head of the bed (HOB) flat at all times.
B) Teach the patient to perform the Valsalva maneuver.
C) Administer benzodiazepines on a PRN basis.
D) Perform endotracheal suctioning every hour.

Question 10

A patient who has sustained a nondepressed skull fracture is admitted to the acute medical unit. Nursing care should include which of the following?

A) Preparation for emergency craniotomy
B) Watchful waiting and close monitoring
C) Administration of inotropic drugs
D) Fluid resuscitation

Question 11

A patient who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the patients current health status is most likely to have precipitated this event?

A) The patient received a blood transfusion.
B) The patients analgesia regimen was recent changed.
C) The patient was not repositioned during the night shift.
D) The patients urinary catheter became occluded.

Question 12

A patient is admitted to the neurologic ICU with a spinal cord injury. In writing the patients care plan, the nurse specifies that contractures can best be prevented by what action?

A) Repositioning the patient every 2 hours
B) Initiating range-of-motion exercises (ROM) as soon as the patient initiates
C) Initiating (ROM) exercises as soon as possible after the injury
D) Performing ROM exercises once a day

Question 13

A patient with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. What is the nurses best intervention for preventing injury?

A) Restrain the patient as ordered.
B) Administer opioids PRN as ordered.
C) Arrange for friends and family members to sit with the patient.
D) Pad the side rails of the patients bed.

Question 14

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?

A) Check the patients indwelling urinary catheter for kinks to ensure patency.
B) Lower the HOB to improve perfusion.
C) Administer analgesia.
D) Reassure the patient that headaches are expected after spinal cord injuries.

Question 15

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?

A) Epidural hemorrhage
B) Hypertensive emergency
C) Spinal shock
D) Hypovolemia

Question 16

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?

A) To decrease cerebral arterial pressure
B) To avoid impeding venous outflow
C) To prevent flexion contractures
D) To prevent aspiration of stomach contents

Question 17

A patient with a $\mathrm{T} 2$ injury is in spinal shock. The nurse will expect to observe what assessment finding?

A) Absence of reflexes along with flaccid extremities
B) Positive Babinskis reflex along with spastic extremities
C) Hyperreflexia along with spastic extremities
D) Spasticity of all four extremities

Question 18

A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?

A) Reflex activity
B) Level of consciousness
C) Cognitive ability
D) Sensory involvement

Question 19

The 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? Select all that apply.

A) Absence of pain response
B) Apnea
C) Coma
D) Absence of brain stem reflexes
E) Absence of deep tendon reflexes

Question 20

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?

A) Complete the pin site care to decrease risk of infection.
B) Notify the neurosurgeon of the occurrence.
C) Stabilize the head in a lateral position.
D) Reattach the pin to prevent further head trauma.

Question 21

The 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 within acceptable limits. What will be the primary goal of initial therapy?

A) Promoting adequate circulation
B) Treating the childs increased ICP
C) Assessing secondary brain injury
D) Preserving brain homeostasis

Question 22

A patient is admitted to the neurologic ICU with a suspected diffuse axonal injury. What would be the primary neuroimaging diagnostic tool used on this patient to evaluate the brain structure?

A) MRI
B) PET scan
C) X-ray
D) Ultrasound

Question 23

A 13-year-old was brought to the ED, unconscious, after being hit in the head by a baseball. When the child regains consciousness, 5 hours after being admitted, he cannot remember the traumatic event. MRI shows no structural sign of injury. What injury would the nurse suspect the patient has?

A) Diffuse axonal injury
B) Grade 1 concussion with frontal lobe involvement
C) Contusion
D) Grade 3 concussion with temporal lobe involvement

Question 24

An 82-year-old man is admitted for observation after a fall. Due to his age, the nurse knows that the patient is at increased risk for what complication of his injury?

A) Hematoma
B) Skull fracture
C) Embolus
D) Stroke

Question 25

A neurologic flow chart is often used to document the care of a patient with a traumatic brain injury. At what point in the patients care should the nurse begin to use a neurologic flow chart?

A) When the patients condition begins to deteriorate
B) As soon as the initial assessment is made
C) At the beginning of each shift
D) When there is a clinically significant change in the patients condition

Question 26

The nurse planning the care of a patient with head injuries is addressing the patients nursing diagnosis of sleep deprivation. What action should the nurse implement?

A) Administer a benzodiazepine at bedtime each night.
B) Do not disturb the patient between 2200 and 0600 .
C) Cluster overnight nursing activities to minimize disturbances.
D) Ensure that the patient does not sleep during the day.

Question 27

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?

A) Help the family understand that the patient could have died.
B) Emphasize the importance of accepting the patients new limitations.
C) Have the members of the family plan the patients inpatient care.
D) Assist the family in setting appropriate short-term goals.

Question 28

The school nurse is giving a presentation on preventing spinal cord injuries (SCI). What should the nurse identify as prominent risk factors for SCI? Select all that apply.

A) Young age
B) Frequent travel
C) African American race
D) Male gender
E) Alcohol or drug use

Question 29

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?

A) Ensure that the player is not moved.
B) Obtain the players vital signs, if possible.
C) Perform a rapid assessment of the players range of motion.
D) Assess the players reflexes.

Question 30

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?

A) Baclofen (Lioresal)
B) Dexamethasone (Decadron)
C) Mannitol (Osmitrol)
D) Phenobarbital (Luminal)

Question 31

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. How can the nurse best address this risk?

A) Change the patients position frequently.
B) Provide a high-protein diet.
C) Provide light massage at least daily.
D) Teach the patient deep breathing and coughing exercises.

Question 32

A patient with a spinal cord injury has experienced several hypotensive episodes. How can the nurse best address the patients risk for orthostatic hypotension?

A) Administer an IV bolus of normal saline prior to repositioning.
B) Maintain bed rest until normal BP regulation returns.
C) Monitor the patients BP before and during position changes.
D) Allow the patient to initiate repositioning.

Question 33

A nurse on the neurologic unit is providing care for a patient who has spinal cord injury at the level of $\mathrm{C} 4$ . When planning the patients care, what aspect of the patients neurologic and functional status should the nurse consider?

A) The patient will be unable to use a wheelchair.
B) The patient will be unable to swallow food.
C) The patient will be continent of urine, but incontinent of bowel.
D) The patient will require full assistance for all aspects of elimination.

Question 34

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. What would be the nurses best answer?

A) The sudden increase in BP can raise the ICP or rupture a cerebral blood vessel.
B) The suddenness of the onset of the syndrome tells us the body is struggling to maintain its normal state.
C) Autonomic dysreflexia causes permanent damage to delicate nerve fibers that are healing.
D) The sudden, severe headache increases muscle tone and can cause further nerve damage.

Question 35

The nurse caring for a patient with a spinal cord injury notes that the patient is exhibiting early signs and symptoms of disuse syndrome. Which of the following is the most appropriate nursing action?

A) Limit the amount of assistance provided with ADLs.
B) Collaborate with the physical therapist and immobilize the patients extremities temporarily.
C) Increase the frequency of ROM exercises.
D) Educate the patient about the importance of frequent position changes.

Question 36

Splints have been 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?

A) At the patients request
B) Each morning and evening
C) Every 2 hours
D) One hour prior to mobility exercises

Question 37

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 teams decision regarding this intervention?

A) Urinary retention can have serious consequences in patients with SCIs.
B) Urinary function is permanently lost following an SCI.
C) Urinary catheters should not remain in place for more than 7 days.
D) Overuse of urinary catheters can exacerbate nerve damage.

Question 38

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. What are the potential complications that should be monitored for in this patient? Select all that apply.

A) Orthostatic hypotension
B) Autonomic dysreflexia
C) DVT
D) Salt-wasting syndrome
E) Increased ICP

Question 39

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?

A) Position the patient in a high Fowlers position when in bed.
B) Support the knees with a pillow when the patient is in bed.
C) Perform passive ROM exercises as ordered.
D) Administer NSAIDs as ordered.

Question 40

A patient is admitted to the neurologic ICU with a $\mathrm{C} 4$ spinal cord injury. When writing the plan of care for this patient, which of the following nursing diagnoses would the nurse prioritize in the immediate care of this patient?

A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously