Chapter 39, Caring for Clients With Head and Spinal Cord Trauma

1.The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid? A) Change in the level of consciousness (LOC) B) Signs of increased intracranial pressure (IICP) C) Halo sign D) Swelling Ans: C Feedback: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage. 2.Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? A) Epidural B) Subdural C) Intracerebral D) Cerebral Ans: B Feedback: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull. 3.You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?