Neurologic Trauma TEST BANK

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 -Correct Answer-Ans: C Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture. Numbness, edema, and epistaxis are not directly associated with a basilar skull fracture. 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 -Correct Answer-Ans: B Feedback: If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation. . 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 -Correct Answer-Ans: B Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing. 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 -Correct Answer-Ans: A Feedback: Signs of increasing ICP include slowing of the heart rate ( bradycardia), increasing systolic BP, and widening pulse pressure.