Deck 39: Caring Forclients With Head and Spinal Cord Trauma

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

Answer 1

Subdural

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.

Answer 2

They have the beginning of a pressure sore.

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."

Answer 3

"Spinal shock can last for a week to months until the body adjusts to the damage caused by the injury."

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.

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.

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."

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

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.

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.

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

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

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

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

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

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

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

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

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

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

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.

Question 21

You are caring for a client who has had intracranial surgery and is being discharged home. What instructions would you give the client besides instructions on their medication?

A) Understand that headaches are uncommon.
B) You can cover the incision with your hair.
C) You can expect swelling above the incision.
D) Expect sensory changes, such as hearing a clicking sound, around the bone flap.

Question 22

A client has been brought to the Emergency Department (ED) after a fall off a roof. The client has no cord function below the point of injury. The ED nurse knows what about this client?

A) The client is a male.
B) The client has a severed spinal cord.
C) The client has a head injury.
D) The client is in spinal shock.

Question 23

A client has a spinal cord injury. The home health nurse is making an initial visit to the client at home and plans on reinforcing teaching on autonomic dysreflexia. What symptom would the nurse stress to the client and their family?

A) Slight headache
B) Rapid heart rate
C) Sweating
D) Runny nose

Question 24

The nurse is caring for a client who is scheduled for surgery to relieve pressure on a compressed nerve. The compression does not involve the spinal cord. What kind of spinal nerve root compression does the nurse know this is?

A) Extramedullary
B) Intramedullary
C) Spinal
D) Peripheral

Question 25

You are planning discharge teaching for a client with a newly diagnosed spinal cord injury and their family. You know that you need to teach the client and their family around long-term complications. What complications would you teach them about? Select all that apply.

A) Renal calculi
B) Autonomic dysreflexia
C) Flaccidity
D) Calcium depletion
E) Sexual dysfunction