NURS 5 Neuro Trauma

A patient with neurologic trauma presents with altered level of consciousness, unequal pupil size, and weakness on one side of the body. Which assessment finding should the nurse prioritize?

Altered level of consciousness is a critical finding in a patient with neurologic trauma and may indicate increased intracranial pressure or brain injury.

complete the following sentence by using the lists of options.

Intracranial hemorrhage

&

GCS

a nurse in the ER is monitoring a client who has a cervical spinal cord injury from a fall. the nurse should monitor the client for which of the following complications?

hypotension

absence of bowel sounds

weakened gag reflex

Which of the following is a recognized complication related to the skin integrity due to the use of cervical tongs?

pressure ulcers

Which of the following accurately describes the pathophysiology of intracranial hemorrhage?

Intracranial hemorrhage occurs due to the disruption of normal blood vessel integrity, leading to abnormal bleeding within the skull. This can result in increased intracranial pressure and potential damage to brain tissue.

an acute care nurse receives shift report for a client who has increased ICP. the nurse is told that the pt demonstrates decorticate posturing. which od the following findings should the nurse expect to observe when assessing the client?

plantar flexion of the legs

A client with a spinal cord injury is at risk for autonomic dysreflexia. Which intervention should the nurse prioritize to prevent autonomic dysreflexia?

Maintaining a sitting or semi-upright position is the priority intervention to prevent autonomic dysreflexia. This position helps to reduce the risk of triggering a dysreflexic episode.

Which intervention is appropriate for managing autonomic dysreflexia in a client with a spinal cord injury above the T6 level?

Elevating the head of the bed to a semi-Fowler's position helps to reduce blood pressure and prevent further complications in autonomic dysreflexia.

Which of the following statements accurately differentiates between a complete and an incomplete spinal cord injury?

This statement is accurate. A complete spinal cord injury results in total loss of motor and sensory function below the level of injury. In contrast, an incomplete spinal cord injury allows for some preservation of motor or sensory function below the level of injury

a nurse is planning care for a client who has a halo fixation device. which of the following actions should the nurse include in the plan of care?

monitor the client for an elevated temp

A nurse is teaching a group of nursing students about the pathophysiology of the spinal cord. Which of the following statements by a nursing student indicates understanding?

The descending tracts of the spinal cord carry motor information from the CNS to lower muscle neurons and cause a reaction to occur. Therefore, this statement by the nursing student indicates an understanding of the teaching.

A patient with cervical tong pins requires careful management to prevent complications. Which of the following actions is most appropriate for ensuring proper care of the cervical tong pins?

Daily cleaning of the pin sites with a prescribed antiseptic solution helps to prevent infection, which is a common complication associated with cervical tong pins.

A 65-year-old male patient presents with a hyperextension injury of the neck after a fall. Which of the following cues would most likely indicate central cord syndrome?

Central cord syndrome typically presents with greater motor impairment in the upper extremities than in the lower extremities due to the arrangement of nerve tracts.

a nurse is caring for a pt who has spinal cord injury and suspects the pt is developing autonomic dysreflexia. which of the following actions should the nurse take first?

place the client in a sitting position

Which of the following is a sign of autonomic dysreflexia?

severe headache

A patient is admitted with an incomplete spinal cord injury at the level of T10. Which of the following cues would most likely indicate this type of injury?

loss of sensation and motor function below the waist

Which of the following is a common cue that a patient may be experiencing autonomic dysreflexia?

flushing of the skin

a nurse is assessing a client who has traumatic head injury to determine motor function response. which of the following client responses to painful stimulus is expected?

pushes the painful stimulus away

Which of the following is a serious complication associated with the use of halo traction in patients with cervical spine injuries?

respiratory distress

a home health nurse is caring for a client who is quadriplegic following a spinal cord injury and who is adjusting to the home environment. which of the following client statements indicate the client is adapting?

"i am using the modified feeding utensils at every meal. I still spill, but I'm getting better"

Which of the following is a potential long-term complication of a concussion?

Post-concussion syndrome is a complex disorder with symptoms such as headaches and dizziness lasting for weeks or months after the initial injury.

Which of the following is not a potential complication of autonomic dysreflexia?

blurred vision

A patient with a recent spinal cord injury is diagnosed with anterior cord syndrome. Which of the following best describes the sensory deficits typically associated with this condition?

loss of pain and temperature sensation below the level of injury, with preservation of proprioception and vibratory sense

a nurse on the intensive care unit is caring for a client to has a severe TBI and CPP of 59mmHg. which of the following actions should the nurse take?

adjust the clients head of bed

a nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. which of the following statements should the nurse make?

the purpose of this device is to immobilize the cervical spine

A client with anterior cord syndrome has experienced a spinal cord injury. Which of the following nursing interventions should be prioritized?

assess the client's motor function

a nurse is caring for a client who has paraplegia following an automobile accident. the client is on an intermittent urinary cauterization program. Which of the following findings indicates the need for catheterization?

dribbling of urine

Which nursing intervention is most essential in the acute care of a patient with an incomplete spinal cord injury at the T10 level to prevent complications related to neurogenic shock?

monitoring blood pressure and heart rate frequently

Which of the following is a priority nursing intervention for a client with neurologic trauma?

assessing the pt's level of consciousness

Which of the following is a common sign of a moderate to severe traumatic brain injury (TBI) in a patient?

sudden loss of consciousness

A client with a spinal cord injury at the level of T6 is experiencing severe headache, sweating, and bradycardia. What is the priority hypothesis for this client's symptoms?

autonomic dysreflexia

a nurse is caring for a client who reports a throbbing headache after lumbar puncture. which of the following actions is most likely to facilitate resolution of the headache?

increase fluid intake

a nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading 210/108 mmHg and suspects the client is experiencing autonomic dysrefelxia. which of the following actions should the nurse take first?

place the patient in a high-fowlers position

A patient presents with weakness and loss of function in the upper extremity, along with sensory deficits and spasticity. These symptoms are consistent with which condition?

lateral cord syndrome

a nurse is caring for a client who has had spinal cord injury at the level of the T2-T3 vertebrae. when planning care, the nurse should anticipate which of the following types of disability?

paraplegia

a rehab nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. after a week on the unit, the nurse notes the client is withdrawn and increasing resistant to rehab efforts by the staff. which of the following actions should the nurse take?

establish a plan of care with the client that sets attainable goals.

Which of the following is a management strategy for halo traction?

assessing neurovascular status regularly

A 60-year-old male patient presents to the emergency department with sudden onset of severe headache, nausea, vomiting, and altered level of consciousness. Which of the following symptoms would be a key indicator of an intracranial hemorrhage?

sudden onset of severe headache

a nurse is developing a plan of care for a client who has a spinal fracture and complete spinal cord transection at the level of c5. which of the rehab goals should the nurse add to the clients plan of care?

ability to self-feed with the use of adaptive equipment

a nurse is assessing a client who has a spinal cord injury. which of the following actions should the nurse take to monitor C4 function?

apply downward pressure which the client shrugs his shoulders

Which of the following is a potential complication of intracranial hemorrhage?

seizures

a nurse is planning care for a female client who has t4 spinal cord injury and is at risk for acquiring tract infections. which of the following actions should the nurse include in the patient's plan of care?

encourage fluid intake at and between meals

a nurse is assessing a client who has a concussion from a sports injury. which of the following manifestations should the nurse expect?

sensitivity to light

A patient presents with symptoms consistent with Brown-Séquard syndrome (lateral cord syndrome). Which of the following clinical presentations is most characteristic of this condition?

Ipsilateral loss of motor function and contralateral loss of pain and temperature sensation below the level of injury

Which of the following is a potential neurological complication of intracranial hemorrhage?

seizures

A patient with a recent head injury is at risk for increased intracranial pressure (ICP). Which of the following is the priority nursing intervention to prevent complications related to increased ICP?

monitoring and maintaining airway patency

Which of the following is a common cause of central cord syndrome?

spinal cord compression due to cervical stenosis

A nurse is caring for a 20-year-old client who has a fever and reports severe headache.

Administer a soapsuds enema is incorrect.

Place the client in a lateral position with the knees drawn to the abdomen is correct.

contrast dyes is incorrect. ulation studies is correct.

Place client NPO for 4 to 6 hr is incorrect. Aspiration is not a concern with a lumbar puncture. Clients undergoing a cerebral angiography would be placed on NPO status.

Ensure informed consent is obtained is correct. A lumbar puncture is an invasive procedure. The nurse should ensure that informed consent has been obtained before the procedure occurs.

Administer IV sedation as prescribed is incorrect. Provide education about the procedure is correct.

a nurse is caring for a client who has a t4 spinal cord injury. which of the following client findings should the nurse identify as an indication the client is risk for experiencing autonomic dysreflexia?

the clients bladder becomes distended

Which of the following is a recommended measure for managing a patient with a concussion?

encourage the patient gets plenty of rest and avoids activities that require concentration