Question 1

Which manifestation does the nurse expect to find on assessment of a client with a skull fracture in the frontal fossa?

Accepted Answer

Periorbital ecchymosis, also known as "raccoon eyes," is a common sign of a basilar skull fracture, particularly fractures involving the anterior cranial fossa, which includes the frontal fossa. This manifestation is due to blood tracking down from the fracture site into the soft tissue around the eyes.

Question 2

The nurse is assessing a client with a spinal cord injury. Manifestations include miosis (constricted pupil), anhidrosis (lack of sweat), and ptosis (drooping eyelid) on the affected side. Which additional information causes the nurse to identify Horner's syndrome?

Accepted Answer

Horner's syndrome is characterized by a triad of symptoms: miosis (constricted pupil), anhidrosis (lack of sweat), and ptosis (drooping eyelid), which result from a disruption of the sympathetic nerves. This syndrome is most commonly associated with an injury at the level of T1 and above, as the sympathetic nerve fibers that control the eyes and face originate in the hypothalamus and pass down the spinal cord to exit at the T1 level.

Question 3

A client who sustained a rear-end motor vehicle collision is admitted to the emergency department. Which injury does the nurse expect to be present in the client?

Accepted Answer

Rear-end motor vehicle collisions commonly cause whiplash injuries, which result from the sudden hyperextension (backward motion) followed by hyperflexion (forward motion) of the neck. This motion can cause damage to the neck's muscles, ligaments, and other soft tissues. However, the initial impact typically forces the head and neck into hyperextension.

Question 4

Which manifestation does interruption of the dorsal spinal cord column cause in a client with spinal cord injury?

Accepted Answer

The dorsal (posterior) columns of the spinal cord are responsible for transmitting proprioception, vibration, and fine touch sensations. Interruption or damage to these pathways can lead to a loss of proprioception, which is the sense of body position and movement.

Question 5

The medical reports of a client who experienced an accident show injuries at the sixth thoracic vertebra. Which condition does the nurse suspect in the client?

Accepted Answer

Neurogenic shock can occur due to damage to the central nervous system, such as an injury at the sixth thoracic vertebra. It affects the body's ability to maintain blood pressure, heart rate, and temperature control.

Question 6

The nurse is teaching about the diagnostic tests for spinal cord injury to a group of staff nurses. Which statement made by an attending nurse indicates the need for further teaching?

Accepted Answer

Myelography is a diagnostic imaging test that involves injecting contrast dye into the spinal canal to visualize the spinal cord, nerve roots, and spinal lining (meninges). It is primarily used to detect abnormalities or changes in the spinal canal, including the bones, discs, and spinal cord, rather than demonstrating intrinsic spinal cord pathology. MRI is more suitable for detailed images of the spinal cord itself and its pathologies.

Question 7

The nurse is preparing to discharge an adolescent from the hospital after an injury from playing a contact sport. The client states, "I am really angry I cannot play for the rest of the season. I don't understand the reasoning." On which factual information is the nurse likely to focus?

Accepted Answer

Reinjury, especially in the context of sports and physical activities, increases the risk of long-term problems such as chronic pain, decreased mobility, or more severe injuries. The nurse would focus on explaining the importance of allowing the body to fully heal to prevent such complications.

Question 8

Laboratory reports for a client after an accident show a fracture in the temporal bone of the middle ear. Which type of fracture does the nurse suspect in this client?

Accepted Answer

A basilar skull fracture involves the base of the skull and often includes the temporal bone, which houses the structures of the middle ear.

Question 9

Which factor can cause herniation of the brainstem?

Accepted Answer

Rupture of a cerebral artery can lead to increased intracranial pressure, which can cause brain tissue to shift and potentially result in brainstem herniation.

Question 10

While reviewing the clinical history of a client with brain injury, the nurse finds bruising of the mastoid process behind the ear of the affected side. Which fracture should the nurse suspect in the client?

Accepted Answer

Bruising of the mastoid process, known as Battle's sign, is a classic symptom of a basilar skull fracture. This type of fracture occurs at the base of the skull.

Question 11

The registered nurse is teaching about Brown-Séquard syndrome to a group of student nurses. Which statement made by the student nurse indicates effective learning?

Accepted Answer

Brown-Séquard syndrome is indeed associated with penetrating injuries that result in the hemisection of the spinal cord. This condition leads to a specific pattern of neurological symptoms, including ipsilateral motor function loss and contralateral pain and temperature sensation loss below the level of the injury.

Question 12

A client experienced traumatic brain injury (TBI) participating in a contact sport. The health-care provider is focused on preventing increased intracranial pressure (ICP). Which intervention does the nurse expect the health-care provider to prescribe initially?

Accepted Answer

The answer of A client experienced traumatic brain injury (TBI)...

Question 13

The nurse in an extended care facility assesses a client diagnosed with a diffuse axonal brain injury. The client has been in a persistent coma for 6 months. The client's spouse states, "I just wish he would wake up so that we can resume our normal lives." Which factor does the nurse conclude is not understood by the spouse?

Accepted Answer

Most clients who regain consciousness after a diffuse axonal brain injury are severely impaired, which the spouse may not understand.

Question 14

The nurse is reviewing subdural hematomas with a group of staff nurses. Which statement made by an attending staff nurse indicates understanding?

Accepted Answer

Subdural hematomas occur in the space below the dura mater and above the arachnoid membrane, which is accurately described in option B.

Question 15

Which statement made by the parent of a client with spinal cord injury causes the nurse to suspect an axial loading injury?

Accepted Answer

Axial loading injuries occur when a force is applied along the axis of the spine, such as when diving into a shallow pool and hitting the bottom head-first. This type of injury is consistent with the scenario described in option B.

Question 16

The nurse is assessing a client who presents to the emergency room with a spinal cord injury. Which finding in the client's reports causes the nurse to suspect central cord syndrome?

Accepted Answer

Central cord syndrome is often associated with hyperextension injuries of the cervical spine, which can damage the central part of the spinal cord, affecting the function of the arms more than the legs.

Question 17

The health-care provider prescribes myelography for a client who sustained a spinal cord injury. Which is the rationale for this diagnostic test?

Accepted Answer

Myelography is a diagnostic procedure that involves injecting a contrast dye into the spinal canal to visualize the spinal cord, nerves, and other structures. It is particularly useful for identifying issues with cerebrospinal fluid (CSF) flow, such as blockages or obstructions, which can affect the spinal cord.

Question 18

The nurse is providing care for a young male client with a spinal cord injury. The client expresses concern about the ability to perform sexually. Which nerve does the nurse recognize as being responsible for sexual function?

Accepted Answer

The answer of The nurse is providing care for a...

Question 19

While assessing the motor strength in a client with a spinal cord injury, the nurse finds the movements of the client are active against gravity. Which score does the nurse record? 1.2

Accepted Answer

Movements that are active against gravity are scored as 3 on the muscle strength scale, indicating the ability to move against gravity but not against resistance.

Question 20

The nurse is teaching a family member about providing home care for a client with a T1 spinal cord injury. The nurse stresses bowel and bladder management to avoid autonomic dysreflexia. Which additional care does the nurse reinforce to prevent the complication?

Accepted Answer

Preventing pressure ulcers is crucial as they can trigger autonomic dysreflexia in individuals with spinal cord injuries.

Quiz 35: Brain and Spinal Cord Injury