Adv Med Surg

A client comes to the emergency department with a large scalp laceration after being struck in the head with a glass bottle. After assessment of the client, what does the nurse do before the health care provider sutures the wound?

• Irrigates the wound to remove debris

• Administers an oral analgesic for pain

• Administers acetaminophen (Tylenol) for headache

• Shaves the hair around the wound

• Irrigates the wound to remove debris

Scalp wounds are potential portals of entry for organisms that cause intracranial infections. Therefore, the area is irrigated before the laceration is sutured to remove foreign material and to reduce the risk for infection.

Autonomic dysreflexia can occur with spinal cord injuries above which of the following levels?

• T6

• S2

• L4

• T10

T6

Any client with a lesion above T6 segment is informed that autonomic dysreflexia can occur and that it may occur even years after the initial injury.

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

• Change in level of consciousness (LOC)

• Seizures

• Restlessness

• Pupil changes

• Change in level of consciousness (LOC)

The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not the earliest signs.

A client is being treated for a lumbar spinal injury that occurred 5 days ago and is currently experiencing the symptoms of spinal shock. Characteristic for this condition, the client is unable to move the lower extremities, is being closely monitored for hypotension and bradycardia, and has impaired temperature control. Which would not be an expected outcome of care?

• client maintains mechanical ventilation with minimal mucus accumulation

• client reports no discomfort

• client's skin remains clean, dry, and intact

• client regains bowel elimination capacity

• client maintains mechanical ventilation with minimal mucus accumulation

A client with a lumbar spinal injury would not require mechanical ventilation.

The nurse is caring for a client with a head injury. The client is experiencing CSF rhinorrhea. Which order should the nurse question?

• Insertion of a nasogastric (NG) tube

• Urine testing for acetone

• Serum sodium concentration testing

• Out of bed to the chair three times a day

• Insertion of a nasogastric (NG) tube

Clients with brain injury are assumed to be catabolic, and nutritional support consultation should be considered as soon as the client is admitted. Parenteral nutrition via a central line or enteral feedings administered via an NG or nasojejunal feeding tube should be considered. If cerebrospinal fluid rhinorrhea occurs, an oral feeding tube should be inserted instead of a nasal tube. Serial studies of blood and urine electrolytes and osmolality are done because head injuries may be accompanied by disorders of sodium regulation. Urine is tested regularly for acetone. An intervention to maintain skin integrity is getting the client out of bed to a chair three times daily.

When assessing a client who has experienced a spinal injury, the nurse notes diaphragmatic breathing and loss of upper limb use and sensation. At what level does the nurse anticipate the injury has occurred?

• C3

• C5

• T6

• L1

• C5

The nurse should anticipate that the injury has occurred at level C5. Injuries above C3 result in the loss of spontaneous respiratory function. Clients with injuries at T6 and L1 retain some degree of upper limb use and sensation.

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?

• Symptoms will evolve over a period of 1 week.

• Monitoring is needed as rapid neurologic deterioration may occur.

• The crash cart with defibrillator is kept nearby.

• Bleeding continues into the intracerebral area.

• Monitoring is needed as rapid neurologic deterioration may occur.

The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.

The nurse is caring for a client who is being assessed for brain death. Which are cardinal signs of brain death? Select all that apply.

• Absence of brainstem reflexes

• No brain waves

• Apnea

• Coma

• Absence of brainstem reflexes

• Apnea

• Coma

The three cardinal signs of brain death on clinical examination are coma, the absence of brain stem reflexes, and apnea. Adjunctive tests, such as cerebral blood flow studies, electroencephalography, transcranial Doppler, and brain stem auditory evoked potential, are often used to confirm brain death.

The nurse in the emergency department is caring for a client 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?

• Occipital skull fracture

• Temporal skull fracture

• Frontal skull fracture

• Basilar skull fracture

• Basilar skull fracture

A fracture of the base of the skull is referred to as a basilar skull fracture. Fractures of the base of the skull tend to traverse the paranasal sinus of the frontal bone or the middle ear located in the temporal bone. Therefore, they frequently produce hemorrhage from the nose, pharynx, or ears, and blood may appear under the conjunctiva. An area of ecchymosis (bruising) may be seen over the mastoid (Battle’s sign). Basilar skull fractures are suspected when CSF escapes from the ears (CSF otorrhea) and the nose (CSF rhinorrhea).

A neurotrauma nurse is working in a neuro ICU. What would the nurse know is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury after the spinal shock subsides?

• Tetraplegia

• Areflexia

• Autonomic dysreflexia

• Paraplegia

• Autonomic dysreflexia

Autonomic dysreflexia is an acute emergency and is seen in clients with a cervical or high thoracic spinal cord injury, usually after the spinal shock subsides. Tetraplegia results in the paralysis of all extremities when there is a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Areflexia is a loss of sympathetic reflex activity below the level of injury within 30 to 60 minutes of a spinal injury.

The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?

• Edema to the head and a blackened eye

• Edema to the head with a large scalp laceration

• Edema to the head with fixed pupils

• Edema to the head with bruising of the mastoid process

• Edema to the head with bruising of the mastoid process

Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.

The nurse is planning the care of a client with a TBI in the neurosurgical ICU. In developing the plan of care, what interventions should be a priority? Select all that apply.

• Making nursing assessments

• Setting priorities for nursing interventions

• Anticipating needs and complications

• Initiating rehabilitation

• Ensuring that the client regains full brain function

• Making nursing assessments

• Setting priorities for nursing interventions

• Anticipating needs and complications

• Initiating rehabilitation

The nursing interventions for the client with a head injury are extensive and diverse. They include making nursing assessments, setting priorities for nursing interventions, anticipating needs and complications, and initiating rehabilitation.

Damage to the brain from traumatic injury can be divided into primary and secondary injuries. Which of the following arecauses of secondary brain injury? Select all that apply.

• Cerebral edema

• Ischemia

• Infection

• Seizures

• Hyperthermia

• Cerebral edema

• Ischemia

• Infection

• Seizures

• Hyperthermia

Secondary injury evolves over the ensuing hours and days after the initial injury and can be due to cerebral edema, ischemia, seizures, infection, hyperthermia, hypovolemia, and hypoxia.

The ED is notified that a 6-year-old child is in transit with a suspected brain injury after being struck by a car. The child is unresponsive at this time, but vital signs are within acceptable limits. What will be the primary goal of initial therapy?

• Promoting adequate circulation

• Treating the child's increased ICP

• Assessing secondary brain injury

• Preserving brain homeostasis

• Preserving brain homeostasis

All therapy is directed toward preserving brain homeostasis and preventing secondary brain injury, which is injury to the brain that occurs after the original traumatic event. The scenario does not indicate the child has increased ICP or a secondary brain injury at this point. Promoting circulation is likely secondary to the broader goal of preserving brain homeostasis.

While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

• concussion

• laceration

• contusion

• skull fracture

• Concussion

A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.

The nurse is caring for a client with a traumatic brain injury. Which assessment findings indicate to the nurse that the client is developing Cushing’s reflex? Select all that apply.

• Apical pulse is 42 beats per minute

• Blood pressure is 140/38 mmHg

• Urine output over 100 mL/hr

• Systolic blood pressure is 180 mm/Hg

• Weakness on one side of the body

• Apical pulse is 42bpm

• BP is 140/38

• Systolic BP is 180

Signs of increasing intracranial pressure and Cushing's reflex include bradycardia, widening pulse pressure, elevated systolic blood pressure, and irregular respirations. Badycardia is a heart or apical rate below 50. A widening pulse pressure is typically defined as a large or wide difference between the two blood pressure readings (systolic and diastolic pressure). Widening pulse pressure readings are present when the difference is greater than 60. In this instance the difference between 140 and 38 is 102. Elevated systolic blood pressure and/or hypertension generally have readings above 140 mm/Hg. Urine output is not an indicator for Cushing’s reflex. Weakness on one side of the body or hemiparesis is a finding associated with a stroke.

A client has been diagnosed with a concussion and is preparing for discharge from the ED. The nurse teaches the family members who will be caring for the client to contact the health care provider or return to the ED if the client demonstrates or reports which complications? Select all that apply.

• Headache

• Slurred speech

• Sleeps for short periods of time

• Vomiting

• Weakness on one side of the body

• slurred speech

• Vomiting

• Weakness on one side of the body

Clients are discharged from the hospital or ED once they return to baseline after a concussion. Monitoring includes observing the client for a decrease in level of consciousness (LOC), worsening headache, dizziness, seizures, abnormal pupil response, vomiting, irritability, slurred speech, numbness, or weakness in the arms or legs. In general, the finding of headache in the client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty waking the client should be reported or treated immediately.

A client has sustained a traumatic brain injury with involvement of the hypothalamus. The nurse is concerned about the development of arginine vasopressin deficiency (AVP-D, previously known as diabetes insipidus). Which of the following would be an appropriate nursing intervention to monitor for early signs of AVP-D?

• Take daily weights.

• Reposition the client frequently.

• Assess for pupillary response frequently.

• Assess vital signs frequently.

• Take daily weights.

A record of daily weights is maintained for the client with a traumatic brain injury, especially if the client has hypothalamic involvement and is at risk for the development of arginine vasopressin deficiency (AVP-D). A weight loss will alert the nurse to possible fluid imbalance early in the process.

A client with a spinal cord injury says they have difficulty recognizing the symptoms of urinary tract infection (UTI). Which symptom is an early sign of UTI in a client with a spinal cord injury?

• Lower back pain

• Burning sensation on urination

• Frequency of urination

• Fever and change in urine clarity

• Fever and change in urine clarity

Fever and change in urine clarity as early signs of UTI in a client with a spinal cord injury. Lower back pain is a late sign. A client with a spinal cord injury may not experience a burning sensation or urinary frequency.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified?

• acute

• chronic

• subacute

• intracerebral

• acute

Subdural hematomas are classified as acute, subacute, and chronic according to the rate of neurologic changes. Symptoms progressively worsen in a client with an acute subdural hematoma within the first 24 hours of the head injury.

Which condition occurs when blood collects between the dura mater and arachnoid membrane?

• Intracerebral hemorrhage

• Epidural hematoma

• Extradural hematoma

• Subdural hematoma

• Subdural hematoma

A subdural hematoma is a collection of blood between the dura mater and brain, space normally occupied by a thin cushion of fluid. Intracerebral hemorrhage is bleeding in the brain or the cerebral tissue with the displacement of surrounding structures. An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An extradural hematoma is another name for an epidural hematoma.

The nurse is assigned to care for clients with SCI on a rehabilitation unit. Which signs does the nurse recognize as clinical manifestations of autonomic dysreflexia? Select all that apply.

• Hypertension

• Tachycardia

• Fever

• Diaphoresis

• Nasal congestion

• HTN

• Diaphoresis

• Nasal congestion

Hypertension and diaphoresis are signs of autonomic dysreflexia. Nasal congestion often accompanies autonomic dysreflexia. Bradycardia, not tachycardia, occurs with autonomic dysreflexia. Although the client may be diaphoretic, a fever does not accompany this condition.

The nurse is caring for a client immediately following a spinal cord injury (SCI). Which is an acute complication of SCI?

• Cardiogenic shock

• Tetraplegia

• Spinal shock

• Paraplegia

• spinal shock

Acute complications of SCI include spinal and neurogenic shock and deep vein thrombosis (DVT). The spinal shock associated with SCI reflects a sudden depression of reflex activity in the spinal cord (areflexia) below the level of injury. Cardiogenic shock is not associated with SCI. Tetraplegia is paralysis of all extremities after a high cervical spine injury. Paraplegia occurs with injuries at the thoracic level. Autonomic dysreflexia is a long-term complication of SCI.

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

• Hypotension

• Tachycardia

• Bradycardia

• HTN

• Bradypnea

The bradycardia, hypertension, and bradypnea associated with this deterioration are known as Cushing’s triad, a grave sign. At this point, herniation of the brainstem and occlusion of the cerebral blood flow occur if therapeutic intervention is not initiated immediately.

The office nurse is reviewing an 80-year-old client's reports related to the onset of a severe headache, rated at 9 out of 10 on the pain scale, with recent onset. The client denies any visual changes. At a prior visit to the office a few months ago, the client had reported a ground-level fall as a result of falling off a chair and hitting the back of their head. The client had been taken to the emergency department, where imaging was performed with negative results.

The nurse anticipates that the client has developed _____ and that _____ will be ordered.

The nurse anticipates that the client has developed chronic subdural hematoma and that CT imaging of the brain will be ordered.

Which of the following types of skull fractures may be evident by Battle’s sign?

• Basilar

• Simple

• Comminuted

• Depressed

• Basilar

A clinical manifestation of a basilar skull fracture is the Battle’s sign (an area of ecchymosis may be seen over the mastoid). A simple (linear) fracture is a break in continuity of the bone. A comminuted skull fracture refers to a splintered fracture line. When bone fragments are embedded into the brain tissue, the fracture is depressed.

The nurse is caring for a client with traumatic brain injury (TBI). Which clinical finding, observed during the reassessment of the client, causes the nurse the most concern?

• Temperature increase from 98.0°F to 99.6°F

• Urinary output increase from 40 to 55 mL/hr

• Heart rate decrease from 100 to 90 bpm

• Pulse oximetry decrease from 99% to 97% room air

• Temperature increase from 98.0°F to 99.6°F

Fever in the client with a TBI can be the result of damage to the hypothalamus, cerebral irritation from hemorrhage, or infection. The nurse monitors the client's temperature every 2 to 4 hours. If the temperature increases, efforts are made to identify the cause and to control it using acetaminophen and cooling blankets to maintain normothermia. The other clinical findings are within normal limits.

A client is admitted to the neurologic ICU with a suspected diffuse axonal injury. Which will the nurse prepare the client for to evaluate the brain structure? Select all that apply.

• MRI

• CT

• PET scan

• X-ray

• Ultrasound

• MRI

• CT

CT and MRI scans, the primary neuroimaging diagnostic tools, are useful in evaluating the brain structure. Ultrasound would not show the brain nor would an x-ray. A PET scan shows brain function, not brain structure.

Elevated ICP is most commonly associated with head injury. Which of the following are clinical signs of increased ICP that a nurse should evaluate? Select all that apply.

• Lowered systolic blood pressure

• Respiratory irregularities

• Slow bounding pulse

• Increased cerebral perfusion

• Widened pulse pressure

• respiratory irregularities

• slow bounding pulse

• widened pulse pressure

In the early stages of cerebral ischemia, the vasomotor centers are stimulated and the systemic pressure rises to maintain cerebral blood flow. This is typically accompanied by a slow, bounding pulse and respiratory irregularities. These changes in blood pressure, pulse, and respiration are important clinically because they suggest increased ICP. A sympathetically mediated response causes an increase in the systolic blood pressure, with a widening of the pulse pressure and cardiac slowing.

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the health care provider or return to the ED if the client

• reports a headache.

• reports generalized weakness.

• sleeps for short periods of time.

• vomits.

• vomits

Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

The nurse working on the neurological unit is caring for a client with a basilar skull fracture. During the assessment, the nurse expects to observe Battle's sign, which is a sign of basilar skull fracture. Which of the following correctly describes Battle's sign?

• Ecchymosis over the mastoid

• Bruising under the eyes

• Drainage of cerebrospinal fluid from the nose

• Drainage of cerebrospinal fluid from the ears

• Ecchymosis over the mastoid

With fractures of the base of the skull, an area of ecchymosis (bruising) may be seen over the mastoid and is called Battle's sign. Basilar skull fractures are suspected when cerebrospinal fluid escapes from the ears or the nose.

The nurse is concerned that a client with a traumatic brain injury is developing an endocrine disorder. Which assessment will the nurse complete for this client? Select all that apply.

• Hemoglobin

• Blood glucose

• Urine acetone

• Intake and output

• Serum electrolytes

• blood glucose

• urine acetone

• I&Os

• Serum electrolytes

Brain damage can produce metabolic and hormonal dysfunctions. Endocrine function is evaluated by monitoring blood glucose, urine acetone, intake and output, and serum electrolytes. Hemoglobin level is not a concern when monitoring alterations in a client’s endocrine function.

Clinical manifestations of neurogenic shock include which of the following? Select all that apply.

• Venous pooling in the extremities

• Bradycardia

• Warm skin

• Tachycardia

• Profuse bilateral sweating

• Venous pooling in the extremities

• Bradycardia

• Warm skin

Loss of sympathetic innervation causes a decrease in cardiac output, venous pooling in the extremities, and peripheral vasodilation resulting in mild hypotension, bradycardia, and warm skin. In addition, the client doe not perspire on the paralyzed portions of the body because sympathetic activity is blocked.

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)?

• Position the client in the supine position

• Maintain cerebral perfusion pressure at greater than 50 mm Hg

• Restrain the client, as indicated

• Administer enemas, as needed

• Maintain cerebral perfusion pressure at greater than 50 mm Hg

Maintenance of adequate CPP is important to prevent serious complications of head injury due to decreased cerebral perfusion. The nurse should maintain cerebral perfusion pressure greater than 50 mm Hg to help control increased ICP. Other measures include elevating the head of the bed as prescribed, maintaining the client’s head and neck in neutral alignment (no twisting or flexing the neck), initiating measures to prevent the Valsalva maneuver (e.g., stool softeners), maintaining body temperature within normal limits, administering O2 to maintain PaO2 greater than 90 mm Hg, maintaining fluid balance with normal saline solution, avoiding noxious stimuli (e.g., excessive suctioning, painful procedures), and administering sedation to reduce agitation.

A client sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

• An epidural hematoma

• An extradural hematoma

• An intracerebral hematoma

• A subdural hematoma

• An intracerebral hematoma

Intracerebral hemorrhage (hematoma) is bleeding within the brain, into the parenchyma of the brain. It is commonly seen in head injuries when force is exerted to the head over a small area (e.g., missile injuries, bullet wounds, stab injuries). A subdural hematoma (SDH) is a collection of blood between the dura and the brain, a space normally occupied by a thin cushion of cerebrospinal fluid. After a head injury, blood may collect in the epidural (extradural) space between the skull and the dura.

A client with a C5 spinal cord injury has tetraplegia. After being moved out of the ICU, the client reports a severe throbbing headache. What should the nurse do first?

• Check the client's indwelling urinary catheter for kinks to ensure patency.

• Lower the HOB to improve perfusion.

• Administer PRN analgesia as prescribed.

• Reassure the client that headaches are expected during recovery from spinal cord injuries.

• Check the client's indwelling urinary catheter for kinks to ensure patency.

A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP. Before administering analgesia, the nurse should check the client's catheter, record vital signs, and perform an abdominal assessment. A severe throbbing headache is a dangerous symptom in this client and is not expected.

When the nurse observes that the client has extension and external rotation of the arms and wrists, and extension, plantar flexion, and internal rotation of the feet, the nurse records the client's posturing as which of the following?

• Decerebrate

• Normal

• Flaccid

• Decorticate

• Decerebrate

Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing. The described posturing results from cerebral trauma and is not normal. The client has no motor function, is limp, and lacks motor tone with flaccid posturing. In decorticate posturing, the client has flexion and internal rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Which type of brain injury has occurred if the client can be aroused with effort but soon slips back into unconsciousness?

• Concussion

• Contusion

• Diffuse axonal injury

• Intracranial hemorrhage

• Contusion

Contusions can be characterized by loss of consciousness associated with stupor and confusion. A concussion is a temporary loss of neurologic function with no apparent structural damage. A diffuse axonal injury involves widespread damage to the axons in the cerebral hemispheres, corpus callosum, and brainstem. An intracranial hemorrhage is a collection of blood that develops within the cranial vault.

Which are characteristics of autonomic dysreflexia?

• severe hypertension, slow heart rate, pounding headache, sweating

• severe hypotension, tachycardia, nausea, flushed skin

• severe hypertension, tachycardia, blurred vision, dry skin

• severe hypotension, slow heart rate, anxiety, dry skin

• severe hypertension, slow heart rate, pounding headache, sweating

Autonomic dysreflexia is an exaggerated sympathetic nervous system response. This syndrome is characterized by a severe, pounding headache with paroxysmal hypertension, profuse diaphoresis above the spinal level of the lesion (most often of the forehead), nausea, nasal congestion, and bradycardia.

Which term refers to muscular hypertonicity in a weak muscle, with increased resistance to stretch?

• Akathisia

• Spasticity

• Ataxia

• Myoclonus

• spasticity

Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes. Akathisia refers to restlessness, an urgent need to move around, and agitation. Ataxia refers to impaired ability to coordinate movement. Myoclonus refers to spasm of a single muscle or group of muscles.

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs the nurse that the client has a reddened, macerated area at the base of the sacrum. What would the nurse suspect is going on with the client?

• They are getting spinal contractures.

• They are gaining weight.

• They have the beginning of a pressure sore.

• They need a bath.

• They have the beginning of a pressure sore

Long-term complications include autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain.

The nurse provides care for a client who experiences a spinal cord injury (SCI). Which potential long-term complication(s) should the nurse include in the client’s updated plan of care? Select all that apply.

• pressure injury

• respiratory infection

• autonomic dysreflexia

• spinal shock

• respiratory arrest

• pressure injury

• respiratory infection

• autonomic dysreflexia

Long-term complications include autonomic dysreflexia, pressure ulcers, respiratory infections, urinary and fecal impairment, spasticity and contractures, weight gain or loss, calcium depletion, urinary calculi, sexual dysfunction, and pain. Respiratory arrest and spinal shock are immediate, not long-term, complications of SCI.

The nurse is planning to provide education about prevention in the community YMCA due to the increase in numbers of spinal cord injuries (SCIs). What predominant risk factors does the nurse understand will have to be addressed? Select all that apply.

• Young age

• Male gender

• Older adult

• Substance use disorder

• Low-income community

• Young age

• Male gender

• Substance use Disorder

The predominant risk factors for SCI include young age, male gender, and alcohol and drug use.

A client has sustained a traumatic brain injury. Which of the following is the priority nursing diagnosis for this client?

• Deficient fluid balance related to decreased level of consciousness and hormonal dysfunction

• Ineffective cerebral tissue perfusion related to increased intracranial pressure

• Disturbed thought processes related to brain injury

• Ineffective airway clearance related to brain injury

• Ineffective airway clearance related to brain injury

Maintaining an airway is always the priority. All the other choices are appropriate nursing diagnoses for this client, but the priority is maintenance of the airway.

When caring for a client who is post-intracranial surgery, what is the most important parameter to monitor?

• Signs of infection

• Intake and output

• Nutritional status

• Body temperature

• body temp

It is important to monitor the client's body temperature closely; hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Options A, B, and C are not the most important parameters to monitor.

The nurse is caring for a client following a spinal cord injury who has a halo device in place. The client is preparing for discharge. Which statement by the client indicates the need for further instruction?

• “I will change the vest liner periodically.”

• “If a pin becomes detached, I’ll notify the surgeon.”

• “I can apply powder under the liner to help with sweating.”

• “I’ll check under the liner for blisters and redness.”

• “I can apply powder under the liner to help with sweating.”

Powder is not used inside the vest because it may contribute to the development of pressure injuries. The areas around the four pin sites of a halo device are cleaned daily and observed for redness, drainage, and pain. The pins are observed for loosening, which may contribute to infection. If one of the pins becomes detached, the head is stabilized in a neutral position by one person while another notifies the neurosurgeon. The skin under the halo vest is inspected for excessive perspiration, redness, and skin blistering, especially on the bony prominences. The vest is opened at the sides to allow the torso to be washed. The liner of the vest should not become wet because dampness can cause skin excoriation. The liner should be changed periodically to promote hygiene and good skin care.

The nurse is caring for a client who has sustained a spinal cord injury (SCI) at C5 and has developed a paralytic ileus. The nurse will prepare the client for which of the following procedures?

• Insertion of a nasogastric tube

• A large volume enema

• Digital stimulation

• Bowel surgery

• Insertion of a nasogastric tube

Immediately after a SCI, a paralytic ileus usually develops. A nasogastric tube is often required to relieve distention and to prevent vomiting and aspiration. An enema and digital stimulation will not relieve a paralytic ileus. Bowel surgery is not necessary.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

• Diarrhea

• Placing the client in a sitting position

• Placing a blanket over the client

• Voiding

• placing blanket over the client

An object on the skin or skin pressure may precipitate autonomic dysreflexia. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family?

• Have the client avoid physical exertion

• Emphasize complete bed rest

• Look for signs of increased intracranial pressure

• Look for a halo sign

• Look for signs of increased ICP

The nurse informs the family to monitor the client closely for signs of increased intracranial pressure if findings are normal and the client does not require hospitalization. Signs of increased intracranial pressure include headache, blurred vision, vomiting, and lack of energy or sleepiness. The nurse looks for a halo sign to detect any cerebrospinal fluid drainage.

While riding a bicycle in a race, a client fell into a ditch and sustained a head injury. Another cyclist found the client lying unconscious in the ditch and called 911. What type of concussion does the client most likely have?

• Grade 1 concussion

• Grade 2 concussion

• Grade 3 concussion

• Grade 4 concussion

• Grade 3 concussion

There are three grades of concussion or mild traumatic brain injury defined by the American Academy of Neurology when the injury is sports related (Ruff, Iverson, Barth, et al., 2009). A grade 1 concussion has symptoms of transient confusion, no loss of consciousness, and duration of mental status abnormalities on examination that resolve in less than 15 minutes. A grade 2 concussion also has symptoms of transient confusion and no loss of consciousness, but the concussion symptoms or mental status abnormalities on examination last more than 15 minutes. In a grade 3 concussion, there is any loss of consciousness lasting from seconds to minutes (Ruff et al., 2009).

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

• Herniation

• Autoregulation

• Cushing’s response

• Monro-Kellie hypothesis

• Herniation

Herniation refers to the shifting of brain tissue from an area of high pressure to an area of lower pressure. Autoregulation is an ability of cerebral blood vessels to dilate or constrict to maintain stable cerebral blood flow despite changes in systemic arterial blood pressure. Cushing’s response is the brain’s attempt to restore blood flow by increasing arterial pressure to overcome the increased ICP. The Monro-Kellie hypothesis is a theory that states that, due to limited space for expansion within the skull, an increase in any one of the cranial contents causes a change in the volume of the others.

For a client with an SCI, why is it beneficial to administer oxygen to maintain a high partial pressure of oxygen (PaO₂)?

• So that the client will not have a respiratory arrest

• Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

• To increase cerebral perfusion pressure

• To prevent secondary brain injury

• Because hypoxemia can create or worsen a neurologic deficit of the spinal cord

Oxygen is administered to maintain a high partial pressure of arterial oxygen (PaO2) because hypoxemia can create or worsen a neurologic deficit of the spinal cord.

The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?

• Cervical collar

• Cast

• Traction with weights and pulleys

• Turning frame

• Traction with weights and pulleys

Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.

The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders?

• The second cervical vertebrae

• The first thoracic vertebrae

• The seventh thoracic vertebrae

• The first lumbar vertebrae

• The first thoracic vertebrae

Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.

At which of the following spinal cord injury levels does the client have full head and neck control?

• C5

• C4

• C3

• C2

• C5

At the level of C5, the client should have full head and neck control, shoulder strength, and elbow flexion. At C4 injury, the client will have good head and neck sensation and motor control, some shoulder elevation, and diaphragm movement. At C2 to C3, the client will have head and neck sensation, some neck control, and can be independent of mechanical ventilation for short periods of time.

A nurse is caring for a 16-year-old adolescent with a head injury resulting from a fight after a high school football game. A health care provider has intubated the client and written orders to wean the client from sedation therapy. A nurse needs further assessment data to determine whether:

• they'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

• nutritional protocol will be effective after the client sedation therapy is tapered.

• to continue IV administration of other scheduled medications.

• payment status will change if the client isn't sedated.

• they'll have to apply restraints to prevent the client from dislodging the endotracheal (ET) tube.

When the client isn't sedated, they may make attempts to remove the ET tube without realizing what they're doing. The nurse needs to obtain information to determine whether it's necessary to request an order for restraints. The nurse doesn't need to obtain additional data to determine if the nutritional protocol will continue to reflect the client's needs because this aspect of care won't change. The client doesn't require additional assessments to continue I.V. administration of medications. I.V. medication clearly needs to continue because the client is intubated. The staff nurse doesn't need to monitor payment status because client sedation shouldn't affect payment status.

A client with a T4-level spinal cord injury (SCI) reports severe headache. The nurse notes profuse diaphoresis of the client's forehead and scalp and suspects autonomic dysreflexia. What is the first thing the nurse will do?

• Place the client in a sitting position.

• Lay the client flat.

• Apply antiembolic stockings.

• Notify the health care provider.

• Place the client in a sitting position.

The nurse immediately places the client in a sitting position to lower blood pressure. Next, the nurse will do a rapid assessment to identify and alleviate the cause, and then check the bladder and bowel. The nurse will examine skin for any places of irritation. If no cause can be found, the nurse will give an antihypertensive as ordered and continue to look for cause. They watch for rebound hypotension once cause is alleviated. Antiembolic stockings will not decrease the blood pressure.

A patient with decompensated heart failure develops hypotension after aggressive diuresis. The provider orders intravenous fluids.Which nursing action is most appropriate?

• Question the order because patients with heart failure should never receive IV fluids.

• Delay fluid administration until a chest x-ray is obtained.

• Administer the prescribed fluids while closely monitoring lung sounds, oxygenation, urine output, and signs of fluid overload.

• Administer the entire fluid bolus rapidly because the blood pressure is low.

• Administer the prescribed fluids while closely monitoring lung sounds, oxygenation, urine output, and signs of fluid overload.

Patients with heart failure may require cautious fluid administration despite the risk of fluid overload. Ongoing assessment and reassessment are essential to balance improving perfusion while preventing pulmonary edema.

Which assessment finding best indicates that intravenous fluid resuscitation is improving tissue perfusion?

• Increasing peripheral edema

• Decreasing serum lactate with improving urine output

• Urine output of 10 mL/hour

• Increasing oxygen requirements

• Decreasing serum lactate with improving urine output

Improving tissue perfusion is reflected by increasing urine output, improving mental status, normalization of blood pressure, and decreasing serum lactate. These findings indicate improved organ perfusion and response to therapy.

A nurse is caring for a patient admitted with septic shock. The provider orders a 1-liter Lactated Ringer's bolus. What is the primary goal of administering this fluid?

• Correct anemia by increasing oxygen-carrying capacity

• Reduce serum sodium concentration

• Replace clotting factors

• Restore circulating volume and improve tissue perfusion

• Restore circulating volume and improve tissue perfusion

The primary purpose of fluid resuscitation is to restore intravascular volume, improve tissue perfusion, and support oxygen delivery to vital organs. IV fluids do not increase oxygen-carrying capacity or replace clotting factors.

A nurse understands that isotonic crystalloid solutions are commonly used during fluid resuscitation because they primarily:

• Replace plasma proteins

• Expand the extracellular fluid compartment without significant fluid shifts into or out of cells

• Move water into the intracellular compartment

• Pull water from the interstitial space through oncotic pressure

• Expand the extracellular fluid compartment without significant fluid shifts into or out of cells

Isotonic crystalloids remain within the extracellular compartment and are commonly used to expand intravascular volume during fluid resuscitation without causing major shifts in cellular water.

A patient with acute blood loss from a motor vehicle collision presents with hypotension and tachycardia. Which intravenous fluid would the nurse anticipate administering first?

• D5W

• 3% Hypertonic Saline

• LR

• 0.45% Normal Saline

• LR

Balanced isotonic crystalloids such as Lactated Ringer's are recommended as first-line fluid therapy for many patients requiring volume resuscitation. Hypotonic and hypertonic solutions are not appropriate for initial treatment of hypovolemic shock.

Which of the following is a common cause of traumatic brain injury (TBI)?

• Drowning

• Falls

• Allergic reactions

• Food poisoning

• Falls

Falls are one of the most common causes of traumatic brain injury (TBI), along with firearm-related injuries, motor vehicle injuries, and assaults. Drowning, allergic reactions, and food poisoning are not common causes of TBI

The nurse is providing diet-related advice to a client following a cerebrovascular accident (CVA). The client wants to minimize the volume of food and yet meet all nutritional elements. Which of the following suggestions should the nurse give to the client about controlling the volume of food intake?

• Provide thickened commercial beverages and fortified cooked cereals.

• Include dry or crisp foods and chewy meats.

• Always serve hot or tepid foods.

• Provide a high-fat diet.

• Provide thickened commercial beverages and fortified cooked cereals.

clients with CVA or other cerebrovascular disorders should lose weight and therefore should minimize their volume of food consumption. To ensure this, the nurse may provide thickened commercial beverages, fortified cooked cereals, or scrambled eggs. clients should avoid eating high-fat foods, and serving foods hot or tepid will not minimize the volume consumed by the client. Foods such as peanut butter, bread, tart foods, dry or crisp foods, and chewy meats should also be avoided because they cause choking.

During a client's recovery from stroke, the nurse should be aware of predictors of stroke outcome in order to help clients and families set realistic goals. What are the predictors of stroke outcome? Select all that apply.

• National Institutes of Health Stroke Scale (NIHSS) score

• Race

• LOC at time of admission

• Gender

• Age

• NIHSS score

• LOC at time of admission

• age

It is helpful for clinicians to be knowledgeable about the relative importance of predictors of stroke outcome (age, NIHSS score, and LOC at time of admission) to provide stroke survivors and their families with realistic goals. Race and gender are not significant predictors of stroke outcome.

A client has been diagnosed as having global aphasia. The nurse recognizes that the client will be unable to perform which action?

• Comprehend spoken words

• Form words that are understandable

• Form words that are understandable or comprehend spoken words

• Speak at all

• Form words that are understandable or comprehend spoken words

Global aphasia is a combination of expressive and receptive aphasia and presents a tremendous challenge to the nurse to effectively communicate with the client. In receptive and expressive aphasia, the client is unable to form words that are understandable. The client who is unable to speak at all is referred to as mute.

How often should neurologic assessments and vital signs be taken initially for the client receiving tissue plasminogen activator (tPA)?

• Every 15 minutes

• Every 30 minutes

• Every 45 minutes

• Every hour

• Every 15 minutes

Neurological assessment and vital signs (except temperature) should be taken every 15 minutes initially while the client is receiving tPA infusion.

Which are contraindications for the administration of tissue plasminogen activator (t-PA)? Select all that apply.

• intracranial hemorrhage

• Ischemic stroke

• Age 18 years or older

• Systolic BP less than or equal to 185 mm Hg

• Major abdominal surgery within 10 days

• intracranial hemorrhage

• Major abdominal surgery within 10 days

Intracranial hemorrhage, neoplasm, aneurysm, and major surgical procedures within 14 days are contraindications to t-PA. Clinical diagnosis of ischemic stroke, being 18 years of age or older, and a systolic BP less than or equal to 185 mm Hg are eligibility criteria.

A client admitted to the emergency department is being evaluated for the possibility of a stroke. Which assessment finding would lead the nurse to suspect that the client is experiencing a hemorrhagic stroke?

• severe exploding headache

• left-sided weakness

• slurred speech

• difficulty finding appropriate words

• severe exploding headache

A hemorrhagic stroke is often characterized by a severe headache (commonly described as the "worst headache ever") or as "exploding." Weakness and speech issues are more commonly associated with an ischemic stroke

Which of the following is the initial diagnostic in suspected stroke?

• Noncontrast computed tomography (CT)

• CT with contrast

• Magnetic resonance imaging (MRI)

• Cerebral angiography

• Noncontrast computed tomography (CT)

An initial head CT scan will determine whether or not the client is experiencing a hemorrhagic stroke. An ischemic infarction will not be readily visible on initial CT scan if it is performed within the first few hours after symptoms onset; however, evidence of bleeding will almost always be visible.

A client is admitted with weakness, expressive aphasia, and right hemianopia. The brain MRI reveals an infarct. The nurse understands these symptoms to be suggestive of which of the following findings?

• Transient ischemic attack (TIA)

• Left-sided cerebrovascular accident (CVA)

• Right-sided cerebrovascular accident (CVA)

• Completed Stroke

• Left-sided cerebrovascular accident (CVA)

When the infarct is on the left side of the brain, the symptoms are likely to be on the right, and the speech is more likely to be involved. If the MRI reveals an infarct, TIA is no longer the diagnosis. There is not enough information to determine if the stroke is still evolving or is complete.

A client presents to the emergency room with reports of having an “exploding headache” for the last 2 hours. The client is immediately seen by a triage nurse who suspects the client is experiencing a stroke. Which of the following is a possible cause based on the characteristic symptom?

• Large artery thrombosis

• Cerebral aneurysm

• Cardiogenic emboli

• Small artery thrombosis

• Cerebral aneurysm

A cerebral aneurysm is a type of hemorrhagic stroke that is characterized by an exploding headache.

While providing information to a community group, the nurse tells them the primary initial symptoms of a hemorrhagic stroke are:

• Weakness on one side of the body and difficulty with speech

• Severe headache and early change in level of consciousness

• Foot drop and external hip rotation

• Confusion or change in mental status

• Severe headache and early change in level of consciousness

The main presenting symptoms for ischemic stroke are numbness or weakness of the face, arm, or leg, especially on one side of the body, confusion or change in mental status, and trouble speaking or understanding speech. Severe headache, vomiting, early change in level of consciousness, and seizures are early signs of a hemorrhagic stroke. Foot drop and external hip rotation can occur if a stroke victim is not turned or positioned correctly.

The nurse is caring for a client having a hemorrhagic stroke. What position in the bed will the nurse maintain this client?

• High-Fowler’s

• Prone

• Supine

• Semi-Fowler's

• Semi-Fowler's

The head of the bed is elevated 15 to 30 degrees (semi-Fowler's position) to promote venous drainage and decrease intracranial pressure.

The nurse is working with a client with dysarthria. The client’s spouse visits daily and wants to know what they can do to help the client with this condition. What statement(s) by the nurse to the client's spouse would be most appropriate to best support the client in improving their speech? Select all that apply.

• "It would be best to limit any questions you ask your spouse to those with 'yes' or 'no' answers."

• "Encourage your spouse to pause between words if you notice they are having difficulty."

• "Suggest to your spouse to practice the exercises the speech therapist recommends."

• "Consider using simple language and concepts when communicating with your spouse."

• "You could ask your spouse to use the communication board or write the word if you are having difficulty understanding."

• "Encourage your spouse to pause between words if you notice they are having difficulty."

• "Suggest to your spouse to practice the exercises the speech therapist recommends."

• "You could ask your spouse to use the communication board or write the word if you are having difficulty understanding."

Dysarthria is a condition where the client cannot use parts of the body that are used to produce speech, such as the tongue, lips, palate, vocal cords, larynx, or breathing. The nurse should encourage the spouse to have the client practice the exercises prescribed by the speech therapist. Pausing briefly between words may be helpful for clients with dysarthria. A communication board or writing the word can also benefit clients with this condition. Yes/No questions are best for clients with another condition called expressive aphasia, not dysarthria. Expressive aphasia is the inability to produce language, but possibly being able to write information. The spouse would not need to use simple language and concepts when communicating with the client, as the client does not have any issues understanding what is being spoken, only with producing speech due to problems with some or all of the body parts that produce speech.

The nurse is caring for a client with aphasia. Which action will the nurse take when communicating with the client? Select all that apply.

• Pause between phrases

• Use gestures when talking

• Face the client when talking

• Talk over the television volume

• Speak in a normal tone of voice

• Pause between phrases

• Use gestures when talking

• Face the client when talking

• Speak in a normal tone of voice

Communicating with a client with aphasia can be challenging. Actions to improve communication include pausing between phrases, using gestures when talking, facing the client when talking, and speaking in a normal tone of voice. Extraneous background noise should be kept to a minimum. Turning off the sound on the television would be beneficial to improve communication.

A client is receiving an IV infusion of mannitol (Osmitrol) after undergoing intracranial surgery to remove a brain tumor. To confirm that this drug is producing its therapeutic effect, the nurse should consider which finding most significant?

• Decreased level of consciousness (LOC)

• Elevated blood pressure

• Increased urine output

• Decreased heart rate

• Increased urine output

The therapeutic effect of mannitol is diuresis, which is confirmed by an increased urine output. A decreased LOC and elevated blood pressure may indicate lack of therapeutic effectiveness. A decreased heart rate doesn't indicate that mannitol is effective.

Which term refers to the inability to perform previously learned purposeful motor acts on a voluntary basis?

• Agnosia

• Agraphia

• Perseveration

• Apraxia

• Apraxia

Verbal apraxia refers to difficulty forming and organizing intelligible words although the musculature is intact. Agnosia is a failure to recognize familiar objects perceived by the senses. Agraphia refers to disturbances in writing intelligible words. Perseveration is the continued and automatic repetition of an activity or word or phrase that is no longer appropriate.

A client has experienced an ischemic stroke that has damaged the lower motor neurons of the brain. Which of the following deficits would the nurse expect during assessment?

• Limited attention span and forgetfulness

• Visual agnosia

• Lack of deep tendon reflexes

• Auditory agnosia

• Lack of deep tendon reflexes

Damage to the occipital lobe can result in visual agnosia, whereas damage to the temporal lobe can cause auditory agnosia. If damage has occurred to the frontal lobe, learning capacity, memory, or other higher cortical intellectual functions may be impaired. Such dysfunction may be reflected in a limited attention span, difficulties in comprehension, forgetfulness, and lack of motivation. Damage to the lower motor neurons may cause decreased muscle tone, flaccid muscle paralysis, and a decrease in or loss of reflexes.

A client undergoes cerebral angiography for evaluation of a subarachnoid hemorrhage. Which findings indicate spasm or occlusion of a cerebral vessel by a clot?

• Nausea, vomiting, and profuse sweating

• Hemiplegia, seizures, and decreased level of consciousness

• Difficulty breathing or swallowing

• Tachycardia, tachypnea, and hypotension

• Hemiplegia, seizures, and decreased level of consciousness

Spasm or occlusion of a cerebral vessel by a clot causes signs and symptoms similar to those of a stroke: hemiplegia, seizures, decreased level of consciousness, aphasia, hemiparesis, and increased focal symptoms. Nausea, vomiting, and profuse sweating suggest a delayed reaction to the contrast medium used in cerebral angiography. Difficulty breathing or swallowing may signal a hematoma in the neck. Tachycardia, tachypnea, and hypotension suggest internal hemorrhage.

A client diagnosed with a stroke is having difficulty forming words during communication. This would be appropriately documented as

• dysphagia.

• receptive aphasia.

• dysarthria.

• diplopia.

• dysarthria.

Dysarthria is difficulty in forming words. Dysphagia is difficulty swallowing. Receptive aphasia is the inability to comprehend the spoken word. Diplopia is double vision.