Deck 73: Management of Clients with Neurologic Trauma

Question 1

Urinary complications can be prevented if the nurse adjusts the care plan to include

A) checking for post void residuals.
B) encouraging voiding every 2 hours.
C) monitoring the client's urinalysis.
D) placing an indwelling Foley catheter.

Answer 1

checking for post void residuals.

Question 2

The nurse is assessing a client for manifestations of recovery from spinal shock. Which of the following assessment findings would indicate that spinal shock is resolving?

A) Flaccid paralysis
B) Hyperreflexia
C) Loss of Babinski's response
D) Urinary retention

Answer 2

Hyperreflexia

Question 3

When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse would interpret this as

A) an incorrect reading.
B) higher than normal.
C) lower than normal.
D) normal.

Answer 3

higher than normal.

Question 4

When the client who has been in flaccid spinal shock dorsiflexes the great toe and fans the other toes when the sole of his foot is stroked, the nurse is

A) alarmed, because this indicates increased ICP.
B) alerted, because this indicates possible meningeal irritation.
C) distressed, because this indicates deterioration.
D) pleased, because this indicates a reduction of spinal shock.

Question 5

The nurse explains to a family that immediate medical-surgical stabilization after a severe cervical injury would include

A) cervical brace.
B) halo jacket.
C) skeletal traction.
D) spinal fusion.

Question 6

The client who is unconscious following a fall has a blood pressure of 90/60 mm Hg. The most appropriate action by the nurse is to

A) increase the patient's intravenous (IV) fluids.
B) notify the physician immediately.
C) provide hyperventilation by adjusting ventilator settings.
D) retake the blood pressure in 15 minutes.

Question 7

To assess motor response, the nurse performing a neurologic assessment on a client in a coma would ask the client to

A) cough and deep breathe.
B) grasp the nurse's fingers.
C) repeat a phrase.
D) wiggle the toes.

Question 8

When the nurse assesses brain tissue extruding through an unstable skull fracture, it is documented as which type of herniation syndrome?

A) Central transtentorial
B) Cingulate
C) Tonsillar
D) Transcalvarial

Question 9

When the client being treated with a hypothermia blanket begins to shiver, the nurse should

A) assess the temperature and blood pressure.
B) increase the O2 to 4 L/minute.
C) give prescribed antipyretic medication.
D) take off the hypothermia blanket.

Question 10

A client arrives in the emergency department after being involved in a motor vehicle accident; the client exhibits a complete loss of motor, sensory, autonomic, and reflex activity below the injury level. The nurse can determine if he is experiencing spinal shock by assessing

A) blood pressure and pulse rate.
B) for muscle spasm.
C) the presence of bowel sounds.
D) the pupillary response.

Question 11

The nurse teaches a group of high school students that the best way to avoid a spinal cord injury is to avoid

A) cervical spondylosis.
B) myelitis.
C) trauma.
D) vascular disease.

Question 12

Vital signs on a brain-injured client 1 hour ago were T 98.8° F, P 76, BP 124/72 . When the nurse takes a current set of vital signs that are T 98.4° F, P 56, BP 160/54, the nurse should

A) administer prn pain medications.
B) check the client's blood glucose level.
C) lower the head of the bed.
D) prepare to administer mannitol.

Question 13

When a client with upper motor neuron damage following a spinal cord injury is experiencing a neurogenic bowel, the nurse would alter the plan of care to include

A) giving a suppository daily.
B) having the client take a daily laxative.
C) instilling daily soapsuds enemas.
D) manually disimpacting the stool.

Question 14

When the client who has an incomplete lesion of the spinal cord complains of more weakness in his upper extremities than in his lower extremities, the nurse recognizes these manifestations to be consistent with

A) anterior cord syndrome.
B) Brown-Séquard syndrome.
C) central cord syndrome.
D) cervical cord syndrome.

Question 15

A client with a spinal cord lesion experiences a sudden, painful spasm of his lower limbs. The priority action by the nurse is to

A) administer pain medication.
B) assess for bladder distention.
C) massage the client's legs.
D) position the client upright.

Question 16

The nurse explains that irreversible brain tissue damage is probable when the blood flow to the brain is reduced by

A) 10%.
B) 30%.
C) 40%.
D) 60%.

Question 17

The nurse encourages the client who has sustained a C5 complete spinal cord injury that he should anticipate that he will be able to

A) dress totally independently.
B) feed himself.
C) learn to type or use a computer.
D) self-catheterize.

Question 18

An elderly client who was found unresponsive at home now opens his eyes when spoken to and answers simple questions when asked; and left alone usually sleeps. The nurse would document this information in the Glasgow Coma Scale using the categories of

A) best verbal response and best motor response.
B) eye opening and best verbal response.
C) eye opening and motor activity.
D) motor activity and motor response.

Question 19

The emergency department nurse should position the client with cranial injuries

A) in high-Fowler position and knees elevated.
B) side-lying with head of bed elevated 20 degrees.
C) supine with head of bed elevated 30 degrees.
D) supine with the bed completely flat.

Question 20

Following a spinal cord injury, assessment revealed left-side motor paralysis with loss of vibratory and position sense, and right-side loss of pain and temperature sensation. The nurse recognizes the spinal cord syndrome of

A) anterior cord syndrome.
B) Brown-Séquard syndrome.
C) central cord syndrome.
D) spinal shock syndrome.

Question 21

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.

Question 22

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.

Question 23

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.

Question 24

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.

Question 25

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.

Question 26

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

Question 27

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.

Question 28

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.