Neurological Assessment and Care of Patients with Head and Spinal Cord Injuries, Exams of Nursing

Download Neurological Assessment and Care of Patients with Head and Spinal Cord Injuries and more Exams Nursing in PDF only on Docsity! 1.The nurse is caring for a client with a head injury after a fall from a hayloft. Which of the following indicates the presence of/or leaking of cerebral spinal fluid? A) Change in the level of consciousness (LOC) B) Signs of increased intracranial pressure (IICP) C) Halo sign D) Swelling Ans: C Feedback: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage. 2.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 Ans: B Feedback: A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull. 3.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 Ans: C Feedback: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma. 4.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 Page 1 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 Ans: C Feedback: 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. 5.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. Ans: C Feedback: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony. 6.A mother brings her 6-year-old to the emergency department (ED) after the child fell off the 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.” Ans: D Feedback: 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. A concussion results in diffuse and microscopic injury to the brain. Options A, B, and C are incorrect because they give incorrect information to the mother. Page 2 shift and is most accurate to report which type of injury? A) Coup injury B) Contusion C) Head injury D) Contrecoup injury Ans: D Feedback: The nurse most accurately reports a contrecoup injury because the client has this type of dual brain injury. The client has experienced not only a direct strike to the brain but the brain ricochets in the skull to the opposite side causing damage and inflammation at that location as well. The client experienced a head injury, which is a general term. The injury is a contusion because it is more serious than a concussion and leads to structural injury to the brain. It is inaccurate to report a coup injury because this reveals injury to the brain itself from a direct strike to the head. 13.The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care? A) The client with history of seizures B) The client who was in a bike accident last summer C) The client who played soccer in college D) The client whose father has Parkinson's disease Ans: C Feedback: The client who has history of playing many years of a physical sport such as soccer and use the head to redirect the ball may have had years of injury to the brain. When concussions occur repetitively, even though they may have not shown injury at that time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy, which can produce neurodegeneration, will need specialized care. The client who has a history of seizures may have no brain injury. The client who was in a previous accident may have had injury, but it is not of a repetitive nature. The client with a father who has Parkinson's disease will have regular follow-up care. 14.A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse? A) The client is a heart transplant recipient. B) The client's medications include warfarin (Coumadin). C) The client is HIV positive. D) The client has a history of concussions from playing hockey. Ans: B Feedback: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for Page 5 intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern. 15.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? A) Symptoms will evolve over a period of 1 week. B) Monitoring is needed as rapid neurologic deterioration may occur. C) The crash cart with defibrillator is kept nearby. D) Bleeding continues into the intracerebral area. Ans: B Feedback: 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. 16.The nurse is caring for a client who continues to have increasingly high intracranial pressure. Which complication is expected unless intracranial pressure is resolved? A) Additional inflammation occurs in the brain. B) Blood vessels dilate circulating blood. C) Herniation occurs through the foramen magnum. D) Venous congestion occurs causing peripheral edema. Ans: C Feedback: Unless intracranial pressure is resolved, the brain will shift to the lateral side or herniate downward through the foramen magnum. Inflammation occurs from damage to the brain but will reach a maximum. Blood vessels do not dilate as a result of intracranial pressure. Peripheral edema is not a concern. 17.The nurse is caring for a client following intracranial surgery. In the plan of care, the nurse states to remove antiembolism stockings. What would the nurse do to accurately complete this intervention? A) Remove the antiembolism stockings nightly and reapply by 8 AM. B) Place the antiembolism stockings on the lower extremities as tolerated. C) Remove the antiembolism stockings briefly every 8 hours. D) Apply the antiembolism stocking prior to ambulation daily. Ans: C Feedback: The nurse is correct to identify time frames on nursing interventions. When caring for a client using antiembolism stockings following surgery, the correct intervention is to Page 6 remove antiembolism stockings briefly every 8 hours. Antiembolism stockings promote circulation and decrease the risk of a thrombus or embolus. 18.The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician? A) The client has periorbital edema and ecchymosis. B) The client's vital signs are temperature, 100.9° F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg. C) The client's level of consciousness has improved. D) The client prefers to rest in the semi-Fowler's position. Ans: B Feedback: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9° F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position. 19.The intensive care unit has four clients received from a violent motor vehicle accident. When assessing the clients, which client would the nurse assess first? A) The client with an open head injury B) The client with a basilar fracture C) The client with a concussion D) The client with a coup injury Ans: B Feedback: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly. 20.The nurse received report from a previous shift. One of her clients was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate? A) The client has cerebral spinal fluid (CSF) leaking from the ear. B) The client has ecchymosis in the periorbital region. C) The client has an elevated temperature. Page 7 that apply. A) Bone demineralization B) Contractures C) Weight bearing D) Spasticity E) Limited range of motion Ans: A, B, D, E Feedback: When planning care for clients with a spinal cord injury, the nurse is correct to recognize the physiologic effects of limited mobility associated with having a spinal cord injury. Bone demineralization occurs due to limited physical activity. Contractures occur due to limited range of motion. Spasticity occurs from the misfiring of neurons. Planning regarding weight bearing is not as important at this time. 27.The nurse is offering suggestions regarding reproductive options to a husband and paraplegic wife. Which option is most helpful? A) Adoption is an option to complete your family but not put your life in jeopardy. B) Conception is not impaired; the birth process is determined with the physician. C) Birth via surrogate is best because your baby can be implanted in another woman. D) Sterilization is best; it would be difficult to care for a baby in your condition. Ans: B Feedback: The nurse's role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, and sterilization is not appropriate. Providing information on that suggestion is appropriate. 28.The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae with bone from which location? A) Iliac crest B) Floating rib C) Femur D) Mandible Ans: A Feedback: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect. 29.A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of cell transplantation therapy. Which early outcome of treatment is anticipated? A) Cell transplantation therapy produced a reduction in swelling and pain. B) Cell transplantation therapy allowed organs to be brought from one person to another. Page 10 C) Cell transplantation therapy improves the growth of new neurologic connections. D) Cell transplantation therapy allows the replacement of nerve cells that are damaged. Ans: D Feedback: Nerve cells in the central nervous system lose the ability to regenerate when injured. Consequently, there is a focus on finding cells that, when transplanted, can replace the nerve cells that have been damaged. The early outcome of transplantation is the replacement. A later outcome of the transplantation is that nerve transmission improves and muscle functions improve or there is a reduction in symptoms. 30.A 58-year-old client has scheduled a sick visit to the physician's office, stating symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and identified potential causes of the pain. Which area of the drawing would the nurse emphasize? A) Spinal cord pathway B) Nucleus pulposus C) Bony vertebrae D) Associated musculature Ans: B Feedback: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms. 31.A client presents to the emergency department stating numbness and tingling occurring down the left leg into the left foot. When documenting the experience, which medical terminology would the nurse be most correct to report? A) Sciatic nerve pain B) Herniation C) Paresthesia D) Paralysis Ans: C Feedback: When a client reports numbness and tingling in an area, he is reporting a paresthesia. The nurse would document the experience as such or place the client's words in parenthesis. The nurse would not make a medical diagnosis of sciatic nerve pain or herniation. The symptoms are not consistent with paralysis. 32.The nurse is caring for a client with a herniation of C4. What item does the nurse Page 11 anticipate to use if conservative therapy is used? A) A cervical collar B) Bandages and tape C) A firm mattress D) Traction equipment Ans: A Feedback: A C4 injury is in the cervical spine region. A herniated cervical disk is treated conservatively (not surgically) by immobilizing the cervical spine with a cervical collar. Dressing supplies are not needed unless there is a wound. A firm mattress is appropriate for a lumbar herniation. Traction equipment is not used on cervical vertebrae. 33.The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious stating, “What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain.” The nurse is most correct to turn the teaching to which surgical procedure? A) A diskectomy B) A laminectomy C) A spinal fusion D) Aggressive traction Ans: C Feedback: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A diskectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option. 34.The nurse is working on a neurosurgical unit. Which of the following nursing interventions are included in the plan of care following spinal surgery? Select all that apply. A) Monitor vital signs B) Intake and output C) Coughing and deep breathing D) PEARLA E) Neurovascular assessment of the lower extremity F) Dressing assessment Ans: A, B, C, E, F Feedback: All of the following nursing interventions would be included in the plan of care except for PEARLA. Assessment of the pupils is informative for a client with neurologic symptoms resulting from a head injury. Page 12