Question 1

The client with a spinal cord injury asks the nurse why he must stand on the tilt table every day. The nurse should base the answer on the fact that weight-bearing
A) decreases leg spasms.
B) improves circulation.
C) prevents bone demineralization.
D) strengthens muscles in the legs.

Accepted Answer

Weight-bearing stimulates osteoblastic activity and thus decreases the demineralization of bone that develops with prolonged immobilization.

Question 2

The nurse is caring for a spinal cord-injured client in outpatient rehabilitation and evaluates that goals for the diagnosis Anticipatory Grieving have been met when the client
A) can function appropriately in the real world.
B) is able to power his/her own adapted vehicle.
C) starts attending vocational rehabilitation.
D) stops making sexually inappropriate comments.

Accepted Answer

Option a is the best indicator that goals for this diagnosis have been met. The other options all show some improvement or movement in the right direction, but option a is a much more comprehensive outcome.

Question 3

A priority nursing intervention for a client in the emergency department with a suspected spinal cord injury is to
A) administer mannitol.
B) give a tetanus booster shot.
C) logroll the client.
D) obtain a thorough history.

Accepted Answer

To prevent further injury to the client with a suspected spinal cord injury, the nurse (and other members of the health care team) should logroll the client. Mannitol is used for increased intracranial pressure. A tetanus booster may or may not be indicated, depending on if any skin was broken. While a thorough history is important, client safety is paramount.

Question 4

While caring for a spinal cord-injured client, the nurse notes that he is flushed and sweating profusely, complaining of headache and nausea, and that his blood pressure is elevated with a slow pulse rate. The priority intervention should be to
A) administer antihypertensive medication.
B) check for a distended bladder.
C) elevate the head of the bed to a sitting position.
D) notify the physician immediately.

Accepted Answer

If autonomic dysreflexia does occur, elevate the head of the bed to a sitting position immediately, check the blood pressure, check for possible sources of irritation, remove the stimulus if it can be done quickly, administer antihypertensive medications per order, if needed, and notify the physician.

Question 5

The trauma nurse working in the emergency department is aware that caring for elderly clients who have head injuries differs from that given to the general population because (Select all that apply)
A) an older client may be less able to tolerate respiratory problems.
B) automobile accidents are a frequent cause and lead to driver's license revocation.
C) clients often have an atypical presentation.
D) poor stamina may impede participation in rehabilitation.
E) Pre-existing cognitive problems impact recovery potential.

Accepted Answer

Many factors make caring for the elderly client with head injury more challenging. Besides options a, c, d, and e, the presence of chronic diseases may make managing ventilation and fluid balance more difficult. Medical complications may impede recovery and cardiac dysrhythmias are less tolerated. Head injury from auto accidents is not as common as in the younger population but often occurs from falls.

Question 6

The nurse explains to the family of a client with a traumatic brain injury (TBI) that research has shown quality of life can be enhanced by rehabilitation in which of the following areas? (Select all that apply)
A) Cognitive skills
B) Emotional adjustment
C) Health maintenance
D) Leisure skills
E) Social skills

Accepted Answer

Interdisciplinary techniques of rehabilitation incorporating all the above options, plus compensatory techniques and physical fitness, have the best results and the best chance to lead to the TBI client living a satisfying and productive life.

Question 7

The nurse working with an ICP monitor institutes which actions? The nurse (Select all that apply)
A) administers prophylactic antibiotics as ordered.
B) limits the number of times the system is opened.
C) manipulates the catheter frequently to ensure patency.
D) uses strict aseptic technique to change dressings.

Accepted Answer

Intracranial monitors all carry a high risk of infection, and because of their placement an infection has serious consequences. Interventions to minimize the risk of infection include options a, b, and d. The monitoring system is manipulated as little as possible and left in for the shortest amount of time possible.

Question 8

A male client with a spinal cord injury at the level of C5 is despondent relative to the termination of sexual relations because of his injury. The nurse counsels that erections are possible with
A) heat pack to the scrotum.
B) manual stimulation.
C) penile implant.
D) visual imagery.

Accepted Answer

Sexuality is an important aspect of caring for a client with a spinal cord injury. A penile implant is one avenue to continuation of sexual activity; however, the nurse must remember that sexual activity in spinal cord-injured men depends in large part on the location of the injury.

Quiz 73: Management of Clients with Neurologic Trauma

The client with a spinal cord injury asks the nurse why he must stand on the tilt table every day. The nurse should base the answer on the fact that weight-bearing

The nurse is caring for a spinal cord-injured client in outpatient rehabilitation and evaluates that goals for the diagnosis Anticipatory Grieving have been met when the client

A priority nursing intervention for a client in the emergency department with a suspected spinal cord injury is to

While caring for a spinal cord-injured client, the nurse notes that he is flushed and sweating profusely, complaining of headache and nausea, and that his blood pressure is elevated with a slow pulse rate. The priority intervention should be to

The trauma nurse working in the emergency department is aware that caring for elderly clients who have head injuries differs from that given to the general population because (Select all that apply)

The nurse explains to the family of a client with a traumatic brain injury (TBI) that research has shown quality of life can be enhanced by rehabilitation in which of the following areas? (Select all that apply)

The nurse working with an ICP monitor institutes which actions? The nurse (Select all that apply)

A male client with a spinal cord injury at the level of C5 is despondent relative to the termination of sexual relations because of his injury. The nurse counsels that erections are possible with