Trauma/SCI/TBI/ICP NCLEX Questions and answers Graded A+

A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first? a.) Place the client flat in bed b.) Assess patency of the indwelling urinary catheter c.) Give one SL nitroglycerin tablet d.) Raise the head of the bed immediately to 90 degrees - d.) Raise the head of the bed immediately to 90 degrees Rationale: Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn't used for hypertension or dysreflexia. A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF) - b.) Intracranial pressure (ICP) is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP. A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space - a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma A client presents in the emergency department after falling from a roof. A fracture of the femoral neck is suspected. Which of these assessments best support this diagnosis? A.) The client reports pain in the affected leg B.) A large hematoma is visible in the affected extremity C.) The affected extremity is shortened, adducted, and extremely rotated D.) The affected extremity is edematous - C.) The affected extremity is shortened, adducted, and extremely rotated A client who has had a plaster of Paris cast applied to his forearm is receiving pain medication. To detect early manifestations of compartment syndrome, which of these assessments should the nurse make? A.) Observe the color of the fingers B.) Palpate the radial pulse under the cast C.) Check the cast for odor and drainage D.) Evaluate the response to analgesics - D.) Evaluate the response to analgesics A client who was in a motor vehicle accident a few days ago is now complaining of progressive weakness in his arms and upper body while the functioning of his lower limbs is unchanged. Which of the following might this client be experiencing? a.) Central cord syndrome b.) Whiplash syndrome