Deck 22: Care of Patients with Head and Spinal Cord Injuries

Question 1

The nurse is caring for a patient with flaccid paralysis after sustaining a spinal cord injury 3 days earlier.The family excitedly notifies the nurse that the patient has flexed his arm.Which response is best for the nurse to make?

A) "I will give the doctor this wonderful news."
B) "Avoid directly touching the arm muscles so that you don't cause more muscle spasms."
C) "This movement means that the spinal cord is adjusting to the injury."
D) "These muscles spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries."

Answer 1

"These muscles spasms are a type of involuntary movement that happens frequently in patients with spinal cord injuries."

Question 2

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.

Answer 2

There is amnesia related to the incident.

Question 3

After an older adult falls,the nurse suspects the development of a subdural hematoma based on which finding(s)?

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 3

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

Question 4

The nurse is caring for an adolescent who has lower limb paralysis after sustaining a spinal injury yesterday.The patient's anxious mother asks if the paralysis is permanent.Which response is most appropriate for the nurse to make?

A) "It is possible that motor function may or may not return after spinal cord swelling has subsided."
B) "Motor function may improve, but there will always be a deficit."
C) "In all likelihood, the paralysis will be permanent."
D) "Have you asked the physician about your concerns?"

Question 5

The nurse is caring for a patient with a spinal cord injury who develops autonomic dysreflexia (AD).Which action is most important for the nurse to take first?

A) Elevate the head of the bed.
B) Notify the charge nurse.
C) Decrease the IV fluid rate.
D) Administer antihypertensive medication.

Question 6

The nurse is caring for a patient with a closed head injury.Which finding causes the nurse to suspect that the patient has developed diabetes insipidus (DI)?

A) Increased lethargy
B) Widening pulse pressure
C) Copious pale urine output
D) Increasing blood glucose levels

Question 7

The student nurse is planning care for a patient with a recent spinal cord injury.Which intervention indicates that the student nurse requires further instruction regarding appropriate care for this patient?

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 8

The unconscious patient with a closed head injury is on mechanical ventilation.To improve brain perfusion through increased blood pressure,the carbon dioxide (CO₂) should be maintained at what level?

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

Question 9

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

A) Elevate the head of the bed 20 to 30 degrees.
B) Place drip pad or cotton to absorb cerebrospinal fluid (CSF) drainage from the nose or ears.
C) Stimulate the patient to better assess changing level of consciousness (LOC).
D) Reposition the patient frequently for comfort.

Question 10

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain.Which information should the nurse include?

A) These injuries allow the brain to twist on the brainstem.
B) These injuries cause the brain to move forward to strike the anterior interior skull.
C) These injuries allow the brain to compress on itself.
D) These injuries cause the brain to strike the bony area opposite of the site of impact.
E) These injuries cause the brain to lose small amounts of cerebrospinal fluid.

Question 11

Why is the older adult more at risk for a cranial bleed following a head injury?

A) The older adult's brain is smaller, which allows for more movement inside the cranium.
B) The older adult's brain features fragile vessels more likely to rupture.
C) The older adult's brain contains less cerebrospinal fluid (CSF) to cushion the brain.
D) The older adult's brain has less flexible meninges to absorb impact.

Question 12

The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness.The nurse most carefully monitors the patient for which change?

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

Question 13

The nurse is caring for a patient with a neurologic injury who is awake.On assessment,the patient displays mild disorientation to surroundings and time and needs additional verbal cues to stimulate response to commands.The nurse correctly documents the patient's level of consciousness (LOC)by using which term?

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

Question 14

When turning the patient who is in Crutchfield tongs traction,the nurse should employ which technique?

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

Question 15

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

A) To ensure effectiveness of the drug.
B) To avoid fluid overload.
C) To maintain electrolyte balance.
D) To maintain adequate blood pressure (BP).

Question 16

Which position is best for an unconscious patient with a right-sided closed head injury?

A) High Fowler
B) Right side-lying
C) Flat with small pillow under head
D) Head of bed 20 to 30 degrees

Question 17

The emergency room nurse is assessing a newly admitted patient with a head injury.The nurse observes clear drainage from the nose.Which action should the nurse perform first?

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

Question 18

The nurse is caring for a patient with spastic paralysis.Which technique is most appropriate for the nurse to use when moving the patient?

A) Firmly grasp the muscles.
B) Use the palms of hands to support the joints.
C) Log roll the patient as a unit.
D) Perform passive range-of-motion (ROM).

Question 19

In assessing the patient with a significant right intracerebral hemorrhage,the nurse anticipates that the patient will demonstrate which signs?

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

Question 20

A patient presents to 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 21

The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria?

A) An epidural hematoma is related to bleeding from arterial venous source.
B) An epidural hematoma can increase intracranial pressure (ICP) 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 22

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

Question 23

The nurse documents which sign(s)of epidural hematoma in a patient with a closed head injury?

A) Mottling of extremities
B) Periorbital ecchymosis
C) Battle sign
D) Nausea and vomiting
E) PERRLA

Question 24

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

Question 25

The nurse is caring for a patient with 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?

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

Question 26

The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain.Which activities indicate that the patient adequately understands the nurse's teaching?

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 27

The nurse is caring for a patient with (AD).The nurse should assess the patient for which conditions or situations?

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