Question 1

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?
A) Epidural
B) Subdural
C) Intracerebral
D) Cerebral

Accepted Answer

Subdural hematoma results from venous bleeding with blood gradually accumulating in the space below the dura. Epidural hematoma results from arterial bleeding with blood accumulating above the dura. Intracerebral hematoma occurs within the brain tissue itself. Cerebral hematoma is a broad term that can refer to any type of bleeding or blood clot within the brain.

Question 2

The nurse receives a call from the caregiver of a client with a spinal cord injury. The caregiver informs you that the client has a reddened, macerated area at the base of their sacrum. What would the nurse suspect is going on with the client?
A) They are getting spinal contractures.
B) They are gaining weight.
C) They have the beginning of a pressure sore.
D) They need a bath.

Accepted Answer

A reddened and macerated area at the base of the sacrum in a client with spinal cord injury is indicative of a beginning pressure sore, which is a common complication in this population due to prolonged immobilization and decreased sensation in the affected area. It is important for the nurse to assess the severity of the pressure sore and initiate appropriate interventions to prevent further progression and potential complications such as infection.

Question 3

You are caring for a client in spinal shock after a diving accident. The client asks how long the spinal shock is going to last. What would be your best response?
A) "Spinal shock can last for a week to months until the body adjusts to the damage caused by the injury."
B) "Spinal shock will go away as soon as the swelling in the spinal cord disappears."
C) "Spinal shock will disappear when the spinal cord grows back together."
D) "Spinal shock isn't real. This is what your injuries really are."

Accepted Answer

Spinal shock is a temporary condition that can last for a week to months after a spinal cord injury. During this time, reflex activity is lost below the level of injury, leading to a flaccid paralysis. As the body adjusts to the injury, reflex activity gradually returns, and a spastic paralysis may develop. It is important to provide ongoing support and care during this time to promote the best possible outcome for the client.

Question 4

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?
A) Provide a well-balanced diet.
B) Position the client.
C) Keep the client hydrated.
D) Help the client perform exercises.

Accepted Answer

Keeping the client hydrated helps to reduce the potential for thrombi formation and renal calculi in clients with impaired physical mobility. Immobility can lead to decreased blood flow and stasis, which increases the risk of thrombi formation. Adequate hydration helps to prevent stasis by maintaining circulation. Additionally, immobility can lead to the formation of renal calculi, which can be reduced by increasing fluid intake. Therefore, maintaining hydration status is an important nursing intervention to reduce the potential for these complications in clients with impaired physical mobility.

Question 5

Which of the following advice should the nurse give a client with impaired physical mobility to prevent maceration and decrease the potential for bacterial growth?
A) Massage frequently.
B) Keep the skin clean and dry.
C) Change position frequently.
D) Use pressure-relieving devices.

Accepted Answer

The answer of Which of the following advice should the...

Question 6

A mother brings her 6-year-old to the Emergency Department (ED) after the child fell off their bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?
A) "A concussion is a blow to the head that bruises the brain."
B) "A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull."
C) "A concussion is a blow to the head that is minor and has no real consequences."
D) "A concussion is a blow to the head that jars the brain resulting in diffuse and microscopic injury to the brain."

Accepted Answer

A concussion is a blow to the head that jars the brain resulting in diffuse and microscopic injury to the brain. While the injury may be minor, it can still have significant consequences and should always be taken seriously.

Question 7

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
A) Radiography
B) Myelography
C) Neurologic examination
D) Computed tomography (CT) scan

Accepted Answer

A neurologic examination is the best choice to determine the level of spinal cord injury as it involves assessing the client's motor and sensory function at various levels of the body. Radiography, myelography, and CT scans may provide information about the structure of the spinal cord and surrounding tissue, but they do not necessarily indicate the level of injury.

Question 8

A client on your unit is scheduled to have intracranial surgery in the morning. You know which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?
A) Restrict fluids before surgery.
B) Administer prescribed medications.
C) Administer preoperative sedation.
D) Administer an osmotic diuretic.

Accepted Answer

The answer of A client on your unit is scheduled...

Question 9

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?
A) Administer oxygen as prescribed.
B) Use mechanical ventilation.
C) Maintain a patent airway.
D) Suction the airway.

Accepted Answer

Suctioning the airway helps clear secretions when the client is unable to cough effectively, maintaining airway patency and preventing respiratory complications.

Question 10

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?
A) Assess for a halo sign
B) Assess for a wing sign
C) Assess for bloody drainage
D) Assess for crepitus around the nose

Accepted Answer

The halo sign is a test for determining if fluid leaking from the nose is CSF. The nurse places a small amount of fluid on a white dressing or tissue and observes if there is a halo of blood around the fluid. If there is a halo, it suggests CSF leakage.

Question 11

When caring for a client who is post intracranial surgery what is the most important parameter to monitor?
A) Signs of infection
B) Intake and output
C) Nutritional status
D) Body temperature

Accepted Answer

Body temperature is the most important parameter to monitor in a client who is post intracranial surgery because it can indicate infection or other complications.

Question 12

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?
A) Tetraplegia
B) Areflexia
C) Autonomic dysreflexia
D) Paraplegia

Accepted Answer

Autonomic dysreflexia is a potentially life-threatening emergency that can occur in clients with cervical or high thoracic spinal cord injury after spinal shock has subsided. It is caused by a response of the autonomic nervous system to a painful or noxious stimulus below the level of injury, resulting in a sudden and severe increase in blood pressure. Symptoms include sudden onset of bradycardia, hypertension, headache, sweating, flushing, nasal congestion, and piloerection. Prompt recognition and treatment are necessary to prevent serious complications such as seizures, stroke, or even death. Tetraplegia and paraplegia are not acute emergencies but rather refer to the extent of paralysis (quadriplegia or paraplegia) resulting from a spinal cord injury. Areflexia refers to the absence of reflexes and may be present in spinal shock but is not an emergency.

Question 13

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
A) Extradural hematoma
B) Epidural hematoma
C) Subdural hematoma
D) Intracranial hematoma

Accepted Answer

An epidural hematoma is an arterial bleed that results in rapid neurologic deterioration due to the buildup of blood between the skull and the dura mater.

Question 14

You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply.
A) Bladder distention
B) Poikilothermia
C) Loss of hunger sensation
D) Circulatory failure
E) No perspiration below the level of the injury

Accepted Answer

Spinal shock is characterized by a temporary loss of reflexes and autonomic function below the level of injury, leading to bladder distention, poikilothermia (inability to regulate body temperature), and absence of perspiration below the injury level.

Question 15

The nursing instructor is talking about the care of clients with spinal cord injuries. What would the instructor teach is used to treat muscle spasms?
A) Skin traction
B) Hot moist packs
C) Tranquilizer
D) Analgesics

Accepted Answer

The answer of The nursing instructor is talking about the...

Question 16

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?
A) Cervical collar
B) Cast
C) Traction with weights and pulleys
D) Turning frame

Accepted Answer

Traction with weights and pulleys is typically used to provide correct vertebral alignment and increase the space between the vertebrae in a client with spinal cord injury. A cervical collar may be used for neck stabilization, but it does not provide the same level of support and alignment. A cast is not typically used for spinal cord injuries, and a turning frame is used for turning and repositioning clients with limited mobility.

Question 17

The nurse is caring for a client with a head injury after a fall from a hayloft. What aspect helps the nurse to detect cerebrospinal fluid(CSF) drainage when examining a client after a significant head injury?
A) Change in the level of consciousness (LOC)
B) Signs of increased intracranial pressure (IICP)
C) Halo sign
D) Swelling

Accepted Answer

The Halo sign is a reliable indicator of CSF leakage after a head injury. It appears as a ring of fluid around a spot of blood on a dressing or bed linen, indicating that CSF is leaking from the nose or ear. A change in LOC, signs of IICP, and swelling may indicate a head injury but do not specifically detect CSF drainage.

Question 18

Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm?
A) Skeletal traction
B) Sleeping on a hard mattress with a bed board
C) Cool, moist compresses
D) Skin traction

Accepted Answer

The answer of Conservative treatment of a compressed nerve root...

Question 19

The client has been brought to the Emergency Department by their caregiver. The caregiver says that they found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when they came on shift. What are these symptoms indicative of?
A) Concussion
B) Autonomic dysreflexia
C) Spinal shock
D) Contusion

Accepted Answer

These symptoms are indicative of autonomic dysreflexia, which is a potentially life-threatening condition that can occur in individuals with spinal cord injuries. It is characterized by a sudden onset of high blood pressure, diaphoresis, and other autonomic symptoms in response to a noxious stimulus below the level of injury. Immediate medical attention is required to prevent complications such as seizures, stroke, or myocardial infarction.

Question 20

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?
A) Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue.
B) Contusions are deep brain injuries.
C) Contusions are microscopic brain injuries.
D) Contusions occur when the brain is jarred and bounces off the skull on the opposite side from the blow.

Accepted Answer

Contusions are bruises or bleeding of the superficial cerebral tissue. This occurs when the brain is jolted against the skull due to a blow or injury to the head.

Quiz 39: Caring Forclients With Head and Spinal Cord Trauma

Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura?

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

You are caring for a client in spinal shock after a diving accident. The client asks how long the spinal shock is going to last. What would be your best response?

A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility?

Which of the following advice should the nurse give a client with impaired physical mobility to prevent maceration and decrease the potential for bacterial growth?

A mother brings her 6-year-old to the Emergency Department (ED) after the child fell off their bike. The physician diagnoses a concussion. The mother asks the nurse what a concussion is. What should the nurse's response be?

You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?

A client on your unit is scheduled to have intracranial surgery in the morning. You know which nursing intervention helps to avoid intraoperative complications, reduce cerebral edema, and prevent postoperative vomiting?

A client with spinal trauma tells the nurse they cannot cough. What nursing intervention should the nurse perform when a client with spinal trauma may not be able to cough?

A client has been admitted for observation after a closed head injury. There is clear fluid leaking from the client's nose. How would the nurse assess if this drainage is CSF?

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

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?

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?

You suspect that a newly admitted client is in spinal shock. What are the symptoms of spinal shock? Select all that apply.

The nursing instructor is talking about the care of clients with spinal cord injuries. What would the instructor teach is used to treat muscle spasms?

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?

The nurse is caring for a client with a head injury after a fall from a hayloft. What aspect helps the nurse to detect cerebrospinal fluid(CSF) drainage when examining a client after a significant head injury?

Conservative treatment of a compressed nerve root is first line treatment. What conservative treatment is used to increase the distance between vertebrae and decrease severe muscle spasm?

The client has been brought to the Emergency Department by their caregiver. The caregiver says that they found the client diaphoretic, nauseated, flushed and complaining of a pounding headache when they came on shift. What are these symptoms indicative of?

A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond?