Deck 23: Care of Patients With Head and Spinal Cord Injuries

Question 1

The patient who suffered a spinal cord injury (SCI)3 days ago resulting in flaccid paralysis begins to flex his arm.The concerned family is instructed that this muscle activity may be related to:

A)increased intracranial pressure.
B)increased edema of the cord.
C)return of voluntary motor activity.
D)muscle spasms.

Answer 1

muscle spasms.

Question 2

After an older adult falls,the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.)

A)Increasing irritability
B)Complaint of a dull headache
C)Frequent "nodding off" in chair during the day
D)Focal seizures
E)Staggering gait

Answer 2

Increasing irritability
Complaint of a dull headache
Frequent "nodding off" in chair during the day

Question 3

In assessing the patient with a significant right-sided closed head injury,the nurse would anticipate the patient to demonstrate which sign?

A)Left-sided motor deficit with sluggish right pupil response
B)Right-sided motor deficit with brisk right pupil response
C)Bilateral motor deficit with bilaterally sluggish pupil response
D)Left-sided motor deficit and bilateral PERRLA

Answer 3

Left-sided motor deficit with sluggish right pupil response

Question 4

The patient presents in the health clinic with low back pain that radiates into the buttocks and below the knee.The nurse suspects which condition?

A)Herniated disk
B)Muscle spasm in lower back
C)Spinal cord injury
D)Sciatica

Question 5

The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased:

A)lethargy.
B)pulse pressure.
C)urinary output.
D)blood glucose levels.

Question 6

To avoid stimulation of painful muscle spasms,the nurse will:

A)grasp the muscle firmly when moving the patient.
B)use palms of hands to support joints when moving the patient.
C)log roll the patient as a unit.
D)perform passive range of motion (ROM).

Question 7

In the event of autonomic dysreflexia (AD)in the patient with a spinal cord injury,the initial intervention should be to:

A)elevate the head of the bed to lower blood pressure.
B)notify the charge nurse to get assistance.
C)increase IV fluid rate to ensure adequate circulating volume.
D)administer anti-hypertensive medication.

Question 8

The most beneficial and safe positioning of an unconscious patient who has a right-sided closed head injury is:

A)high Fowler's.
B)right side-lying.
C)flat with small pillow under head.
D)head of bed 20 to 30 degrees.

Question 9

The nurse describes a concussion as a closed head injury in which:

A)the brain tissue is bruised.
B)no loss of consciousness occurs.
C)there is amnesia related to the incident.
D)there are no subsequent symptoms.

Question 10

The nurse assesses the level of consciousness (LOC)of a patient with a neurologic injury as mildly disoriented to surroundings and time,but awake and needs additional verbal cues to stimulate response to commands.Which documentation is the most accurate in regard to LOC?

A)Alert
B)Confused
C)Lethargic
D)Obtunded

Question 11

The nurse is aware that the older adult is more at risk for a cranial bleed following a head injury because the older adult has:

A)a smaller brain, which allows for more movement inside the cranium.
B)fragile vessels more likely to rupture.
C)less cerebrospinal fluid to cushion the brain.
D)less flexibility of the meninges to absorb impact.

Question 12

The patient with a suspected subdural hematoma is on an IV drip of mannitol infusing at 50 mL/hr.The nurse explains that the slow infusion rate is essential for what purpose?

A)Ensure effectiveness of the drug.
B)Avoid fluid overload.
C)Maintain electrolyte balance.
D)Maintain adequate blood pressure.

Question 13

The older adult who is admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness will be observed for which change?

A)Increasing respiratory rate
B)Decreasing heart rate
C)Decreasing pulse pressure
D)Decreasing level of consciousness (LOC)

Question 14

When turning the patient who is in Crutchfield tongs traction,the nurse will:

A)turn the patient as a unit by log rolling.
B)release the weights to prevent injury while turning.
C)turn quickly to avoid muscle spasms.
D)advise the patient to hold his breath and bear down during turning.

Question 15

Following a craniotomy to relieve increased intracranial pressure (ICP),the nurse will implement which intervention?

A)Elevate the head of the bed 30 to 45 degrees.
B)Place drip pad or cotton to absorb cerebrospinal fluid drainage from the nose or ears.
C)Keep the patient stimulated to better assess changing level of consciousness.
D)Allow the patient to change positions frequently for comfort.

Question 16

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?

A)Document the presence of rhinorrhea.
B)Inform the physician of the assessment.
C)Test fluid with a glucose Accu-Chek or Dextrostix.
D)Tape a drip pad under the nose.

Question 17

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain by: (Select all that apply.)

A)allowing the brain to twist on the brainstem.
B)moving forward to strike the anterior interior skull.
C)allowing the brain to compress on itself.
D)striking the bony area opposite the site of impact.
E)losing small amounts of cerebrospinal fluid.

Question 18

The unconscious patient with a closed head injury is on mechanical ventilation.To improve brain perfusion through increased blood pressure,the CO? level is maintained at _____ mm Hg.

A)10 to 15
B)15 to 20
C)20 to 25
D)25 to 30

Question 19

The student nurse is planning care for a patient with a recent spinal cord injury.Which intervention indicates the need for further instruction regarding care of the patient with a spinal cord injury?

A)Keep the halo jacket fastened unless the patient is in a supine position.
B)Monitor the bladder every 4 hours for signs of bladder distention.
C)Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.
D)Assess compression stockings for proper fit.

Question 20

The anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent.Which response by the nurse is most helpful?

A)"Motor function sometimes returns after the edema of the spinal cord has subsided."
B)"Motor function may improve, but there will always be a deficit."
C)"In all likelihood the paralysis will be permanent."
D)"The physician is the best source for that information."

Question 21

The nurse caring for a patient with autonomic dysreflexia assesses the patient for which conditions or situations? (Select all that apply.)

A)Distended bladder
B)Constipation
C)Increased fluid intake
D)Wrinkles in bed linens
E)Abrupt environmental temperature changes

Question 22

The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain.The nurse determines no further teaching is required when observing which patient activities? (Select all that apply.)

A)The patient carries items away from the center of the body.
B)The patient bends the knees, with the back straight, and crouches to lift an item off the floor.
C)The patient uses a lumbar pillow or roll when sitting for long periods.
D)The patient performs proper back exercises twice a day.
E)The patient maintains proper body weight.

Question 23

If conservative measures are unsuccessful in treating a herniated disc,a(n)__________ may be necessary to remove the posterior arch of the vertebra,along with the disk.

Question 24

The nurse documents all the signs of epidural hematoma in a patient with a closed head injury,which are: (Select all that apply.)

A)mottling of extremities.
B)periorbital ecchymosis.
C)Battle's sign.
D)nausea and vomiting.
E)PERRLA.

Question 25

The nurse is aware that increasing intracranial pressure can cause _____________ of the brain,which results in the brain impinging on the brainstem.

Question 26

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)

A)An epidural hematoma is related to bleeding from arterial venous source.
B)An epidural hematoma can increase intracranial pressure quickly.
C)An epidural hematoma changes overall condition quickly.
D)An epidural hematoma can cause death.
E)An epidural hematoma can cause irreversible brain damage.

Question 27

The nurse is caring for a patient who has a complete transection of the cord at C7.The patient asks the nurse what functions he will be able to perform.The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.)

A)Transferring himself
B)Dressing himself
C)Using a wheelchair with standard hand rims
D)Feeding himself
E)Effectively typing using all digits