Question 1

The patient who suffered a spinal cord injury (SCI)3 days ago resulting in flaccid paralysis begins to flex his arm.The concerned family is instructed that this muscle activity may be related to:

Accepted Answer

Muscle spasms occur several days after the spinal cord injury and are spinal recovery indicators.Concerned family should be reminded that spasms are not necessarily an indication of the return of motor function.

Question 2

After an older adult falls,the nurse suspects the development of a subdural hematoma based on which assessment findings? (Select all that apply.)

Accepted Answer

Increasing irritability and complaint of headache as well as changing level of consciousness are signs of increasing intracranial pressure.Seizures and staggering gait are not specifically indicative of subdural hematoma.

Question 3

In assessing the patient with a significant right-sided closed head injury,the nurse would anticipate the patient to demonstrate which sign?

Accepted Answer

A right-sided injury will cause contralateral (opposite side)motor deficit and ipsilateral (same side)pupillary response.

Question 4

The patient presents in the health clinic with low back pain that radiates into the buttocks and below the knee.The nurse suspects which condition?

Accepted Answer

Herniated disks typically cause compression on the sciatic nerve and allow the pain to radiate into the buttocks and leg.Muscle spasm in the lower back will result in back pain.There is no indication of spinal cord injury.Pain from sciatica does not involve back pain.

Question 5

The nurse caring for a patient with an epidural hematoma suspects diabetes insipidus when the patient exhibits increased:

Accepted Answer

A large increase in urinary output of pale urine with a low specific gravity is the clue to the development of diabetes insipidus related to edema of the posterior pituitary.Lethargy and increased pulse pressure are not typical signs of diabetes insipidus.Increased serum glucose levels is a sign of diabetes mellitus.

Question 6

To avoid stimulation of painful muscle spasms,the nurse will:

Accepted Answer

Using the palms of the hands and not grasping the muscle will reduce the incidence of spasm.Log rolling and ROM may initiate spasms.

Question 7

In the event of autonomic dysreflexia (AD)in the patient with a spinal cord injury,the initial intervention should be to:

Accepted Answer

Autonomic dysreflexia (hyperreflexia)response is potentially dangerous to the patient,because it can produce vasoconstriction of the arterioles with an immediate elevation of blood pressure.Elevating the head of bed is the initial intervention to decrease the rising blood pressure.Notifying the charge nurse can be done after initial interventions.Increasing the IV fluid rate may further increase the blood pressure.The cause of AD should be addressed before administering any hypertensive medication.

Question 8

The most beneficial and safe positioning of an unconscious patient who has a right-sided closed head injury is:

Accepted Answer

Keeping the head of the bed 20 to 30 degrees with the body in good alignment will help reduce intracranial pressure and keep the airway patent.

Question 9

The nurse describes a concussion as a closed head injury in which:

Accepted Answer

A concussion is a closed head injury in which there is a brief disruption of consciousness,amnesia,and subsequent headaches that may last for several weeks.

Question 10

The nurse assesses the level of consciousness (LOC)of a patient with a neurologic injury as mildly disoriented to surroundings and time,but awake and needs additional verbal cues to stimulate response to commands.Which documentation is the most accurate in regard to LOC?

Accepted Answer

The confused patient is awake,but slightly confused and needs coaching to respond to commands.Alert indicates appropriate response to questions and commands with little stimulation.Lethargic is described as the patient being drowsy,but easily aroused.Obtunded patients are more difficult to arouse and respond slowly to stimulation.

Question 11

The nurse is aware that the older adult is more at risk for a cranial bleed following a head injury because the older adult has:

Accepted Answer

Atrophy of the brain leaves increased intracranial space,allowing increased movement of the brain in the event of head trauma.

Question 12

The patient with a suspected subdural hematoma is on an IV drip of mannitol infusing at 50 mL/hr.The nurse explains that the slow infusion rate is essential for what purpose?

Accepted Answer

The slow infusion rate will not cause fluid overload,which would add to the possibility of increased intracranial pressure.

Question 13

The older adult who is admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness will be observed for which change?

Accepted Answer

Assessment of level of consciousness provides the greatest amount of information about neurologic condition.A reduction in level of consciousness may signal the onset of complications in the patient who has had a head injury.

Question 14

When turning the patient who is in Crutchfield tongs traction,the nurse will:

Accepted Answer

Turning the patient as a unit by log rolling with the weights in place immobilizes the affected vertebrae and maintains alignment.Releasing the weights or turning quickly will affect vertebrae and alignment.Deep breathing will decrease muscle tension.

Question 15

Following a craniotomy to relieve increased intracranial pressure (ICP),the nurse will implement which intervention?

Accepted Answer

The head of bed is elevated to aid in reduction of ICP.Drip pads,patient stimulation,and changing positions frequently may increase ICP.

Question 16

The emergency room nurse assessing clear drainage from the nose of a newly admitted patient with a head injury should perform which intervention?

Accepted Answer

The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid.Documentation and informing the physician should occur after confirmation of the character of the fluid.

Question 17

The nurse uses a visual aid to demonstrate how a coup-contrecoup injures the brain by: (Select all that apply.)

Accepted Answer

In a coup-contrecoup injury,the brain moves forward,striking the anterior interior wall of the cranium,and moves back,striking the bony area opposite the site of the impact,causing two areas of injury.

Question 18

The unconscious patient with a closed head injury is on mechanical ventilation.To improve brain perfusion through increased blood pressure,the CO? level is maintained at _____ mm Hg.

Accepted Answer

The carbon dioxide level is set to be maintained at 25 to 30 mm Hg to create vascular constriction,raise blood pressure,and perfuse the cerebrum.

Question 19

The student nurse is planning care for a patient with a recent spinal cord injury.Which intervention indicates the need for further instruction regarding care of the patient with a spinal cord injury?

Accepted Answer

Moving or positioning the patient with neurologic injury or surgery should not be delegated to unlicensed personnel.Following proper instruction,the UAP can assist the nurse with moving or repositioning the patient.Halo jackets must be kept fastened unless the patient is in a supine position in order to prevent sudden head movement.Bladder distention should be avoided to prevent infection or autonomic dysreflexia.Compression stockings are used to prevent deep vein thrombosis.

Question 20

The anxious mother of an adolescent who sustained a spinal injury yesterday and has paralysis of the lower limbs asks if the paralysis is permanent.Which response by the nurse is most helpful?

Accepted Answer

Until spinal cord edema has subsided,the extent or the permanency of the paralysis cannot be evaluated.It would be incorrect to indicate that there will definitely be a deficit or paralysis.Not addressing the question and suggesting only to talk to the physician will likely frighten the parent.

Quiz 23: Care of Patients With Head and Spinal Cord Injuries

The patient who suffered a spinal cord injury (SCI) 3 days ago resulting in flaccid paralysis begins to flex his arm.The concerned family is instructed that this muscle activity may be related to: