Chapter 68: Management of Patients with Neurologic Trauma

Chapter 68: Management of Patients with Neurologic Trauma A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care? Monitoring is needed as rapid neurologic deterioration may occur. A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes diaphoresis on the face. What is the first action by the nurse? Place the patient in a sitting position. The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? The client has cerebral spinal fluid (CSF) leaking from the ear. Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? Subdural Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels? T6 When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Body temperature When the nurse observes that the patient has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she records the patient's posturing as which of the following? Decerebrate You are a neuro trauma nurse working in a neuro ICU. What would you know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides? Autonomic dysreflexia The most important nursing priority of treatment for a patient with an altered LOC is to: Maintain a clear airway to ensure adequate ventilation. A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100 mg intravenously twice a day. The medication is supplied in vials containing 125 mg per 2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY. 1.6 Explanation: (100 mg/125 mg) x 2 mL = 1.6 mL. The nurse is caring for a patient diagnosed with an acute subdural hematoma following a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone (Decadron). The medication is available in a 20-mL IV bag and ordered to be infused over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump? 80 mL/hr Explanation: 20/15 × 60 = 80 mL/hr Which of the following is the earliest sign of increasing intracranial pressure (ICP)? Change in level of consciousness (LOC) The nurse is caring for a patient following an SCI who has a halo device in place. The patient is preparing for discharge. Which of the following statements made by the patient indicates the need for further instruction? "I can apply powder under the liner to help with sweating." A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? Acute The nurse is conducting a health fair on spinal cord injury (SCI) at a local high school. The nurse relays that which of the following is the most common cause of SCI? Motor vehicle crashes The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? Conception is not impaired; the birth process is determined with the physician. The nurse reviews the physician's emergency department progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign. The nurse knows that the physician observed which clinical manifestation? An area of bruising over the mastoid bone A client admitted with a cerebral contusion is confused, disoriented, and restless. Which nursing diagnosis takes the highest priority? Risk for injury related to neurologic deficit A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture? Basilar A client with a spinal cord injury is to receive Lovenox (enoxaparin) 50 mg subcutaneously twice a day. The medication is supplied in vials containing 80 mg per 0.8 mL. How many mL will constitute the correct dose? Enter the correct number ONLY. 0.5 Which of the following conditions occurs when bleeding occurs between the dura mater and arachnoid membrane? Subdural hematoma The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? Burr holes A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? Paresthesia The nurse is caring for a patient immediately following a spinal cord injury (SCI). Which of the following is an acute complication of spinal cord injury? Spinal shock A client with quadriplegia is in spinal shock. What finding should the nurse expect? Absence of reflexes along with flaccid extremities The nurse in the emergency department is caring for a patient brought in by the rescue squad after falling from a second-story window. The nurse assesses ecchymosis over the mastoid and clear fluid from the ears. What type of skull fracture is this indicative of? Basilar skull fracture A client in the surgical intensive care unit has skeletal tongs in place to stabilize a cervical fracture. Protocol dictates that pin care should be performed each shift. When providing pin care for the client, which finding should the nurse report to the physician? A small amount of yellow drainage at the left pin insertion site At a certain point, the brain's ability to autoregulate becomes ineffective and decompensation (ischemia and infarction) begins. Which of the following are associated with Cushing's triad? Select all that apply. • Bradycardia • Hypertension • Bradypnea Which of the following are possible long-term complications of spinal cord injury? Select all that apply. • Respiratory infection • Autonomic dysreflexia Which Glasgow Coma Scale score is indicative of a severe head injury? 7 The nurse is caring for a patient in the neurologic ICU who sustained a severe brain injury. Which of the following nursing measures will the nurse implement to aid in controlling ICP? Maintaining cerebral perfusion pressure from 50 to 70 mm Hg A patient comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the patient, what does the nurse do before the physician sutures the wound? Irrigates the wound to remove debris A patient with a concussion is discharged after the assessment. Which of the following instructions should the nurse give the patient's family? Look for signs of increased intracranial pressure A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon her arrival at the emergency department and subsequent diagnostic tests, it was determined that she suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would you expect her subdural hematoma to be classified? Acute When caring for a client who is post-intracranial surgery what is the most important parameter to monitor? Body temperature A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient vomits. Which of the following terms refers to muscular hypertonicity with increased resistance to stretch? Spasticity Which of the following is a clinical manifestation of pupillary changes that indicate increasing ICP? Pupils are showing progressive dilation.