Chapter 73: Management of Clients with Neurologic Trauma Nursing School Test Banks

Black & Hawks: Medical-Surgical Nursing, 8th Edition

Test Bank

Chapter 73: Management of Clients with Neurologic Trauma

MULTIPLE CHOICE

1. 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.

ANS: B

Eye opening: If the eyes are closed, call the clients name. Best verbal response: Verbal responses assess the clients orientation to self, environment, and time. A motor response can be elicited by asking the client to wiggle his/her toes.

DIF: Application/Applying REF: pp. 1929, 1930

OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

2. 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%.

ANS: D

When blood flow to the brain is reduced by 40%, cerebral tissue becomes acidotic. When the blood flow to the brain is reduced by 60% the electroencephalogram (EEG) pattern changes and the client is at risk for significant brain tissue damage. Cerebral metabolism is altered, which eventually leads to brain tissue hypoxia and areas of brain tissue ischemia.

DIF: Comprehension/Understanding REF: p. 1922 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

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

a.

increase the patients intravenous (IV) fluids.

b.

notify the physician immediately.

c.

provide hyperventilation by adjusting ventilator settings.

d.

retake the blood pressure in 15 minutes.

ANS: B

If the physician has not left orders to treat blood pressure changes, notification must occur if the blood pressure range is less than 100 or more than 150 mm Hg systolic. When a client is hypotensive, cerebral perfusion pressure (CPP) falls and the brain is not adequately perfused. The client needs to be kept in a euvolemic state, so raising the IV fluid rate may not be advisable. Hyperventilation is no longer routinely used; it is used in the setting of herniation to avoid compromising cerebral perfusion. Waiting 15 minutes to retake the blood pressure is too long.

DIF: Application/Applying REF: p. 1926 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

4. 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

ANS: D

Transcalvarial herniation describes the situation in which brain tissue is extruded through an unstable skull fracture. Central transtentorial herniation is downward displacement of the diencephalon through the tentorial notch. Cingulate herniation occurs when the frontal lobes of the cerebrum are compressed, resulting in compression of the cingulated gyrus under the falx cerebri. Tonsillar herniation, or cerebellar herniation, occurs when the cerebellar tonsil shifts through the foramen magnum.

DIF: Knowledge/Remembering REF: p. 1923 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

5. 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.

ANS: D

When the client begins to shiver, the metabolic demands increase, robbing the brain of needed oxygen and nutrients. A client undergoing hypothermic treatment should be cool, but not to the point of shivering.

DIF: Application/Applying REF: p. 1932 OBJ: Intervention

MSC: Physiological Integrity Reduction of Risk Potential-Potential for Complications of Diagnostic Tests/Treatments/Procedures

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

a.

administer prn pain medications.

b.

check the clients blood glucose level.

c.

lower the head of the bed.

d.

prepare to administer mannitol.

ANS: D

Cushings triad, or increased systolic blood pressure with widened pulse pressure and bradycardia, is a late response and indicates severe increased ICP with the failure of autoregulation. Treatment of increased ICP includes mannitol, an osmotic diuretic. There is no indication that the client needs pain medication or is hypoglycemic. Generally, the head of the bed in clients with increased intracranial pressure is elevated.

DIF: Analysis/Analyzing REF: p. 1926 OBJ: Intervention

MSC: Physiological Integrity Pharmacological and Parenteral Therapies-Pharmacological Agents/Actions

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 nurses fingers.

c.

repeat a phrase.

d.

wiggle the toes.

ANS: D

Motor responses are assessed by asking the client to follow specific commands, such as wiggle your toes. Do not ask the client to squeeze your hand because grasp is a reflexive response that occurs in clients with head injury.

DIF: Application/Applying REF: p. 1930 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

8. 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.

ANS: C

Place the client with cranial injures supine with the head elevated 30 degrees unless contraindicated (e.g., some spinal injuries, some aneurysms).

DIF: Application/Applying REF: p. 1932 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Illness Management

9. 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.

ANS: B

The ICP reading should be less than 15 mm Hg.

DIF: Knowledge/Remembering REF: p. 1921 OBJ: Assessment

MSC: Physiological Integrity Reduction in Risk Potential-System Specific Assessments

10. 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.

ANS: C

SCIs most often occur as a result of injury to the vertebrae. Most victims are males ages 16-30.

DIF: Comprehension/Understanding REF: p. 1948 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-High Risk Behaviors

11. 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.

ANS: D

When a client previously in flaccid spinal shock begins to exhibit flexion, it is an indication of the reduction of spinal shock.

DIF: Application/Applying REF: p. 1954 OBJ: Assessment

MSC: Physiological Integrity Reduction of Risk Potential-System Specific Assessments

12. 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-Squard syndrome.

c.

central cord syndrome.

d.

cervical cord syndrome.

ANS: C

In central cord syndrome, the weakness is caused by edema and hemorrhage in the central area of the cord, which is predominantly occupied by nerve tracts to the hands and arms.

DIF: Knowledge/Remembering REF: p. 1952 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

13. 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-Squard syndrome.

c.

central cord syndrome.

d.

spinal shock syndrome.

ANS: B

Brown-Squard syndrome is caused by lateral hemisection of the cord. This results in ipsilateral motor paralysis, loss of vibratory and position sense, and contralateral loss of pain and temperature sensation.

DIF: Knowledge/Remembering REF: pp. 1952-1953

OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

14. 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.

ANS: A

The immediate response to cord transection is called spinal shock or post-traumatic areflexia. The spinal cordinjured person experiences complete loss of skeletal muscle function, bowel and bladder tone, sexual function, and autonomic reflexes. Loss of venous return and hypotension also occur.

DIF: Application/Applying REF: p. 1954 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology

15. 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 Babinskis response

d.

Urinary retention

ANS: B

Indications that spinal shock is resolving include the return of reflexes, the development of hyperreflexia rather than flaccidity, and the return of reflex emptying of the bladder.

DIF: Application/Applying REF: p. 1954 OBJ: Assessment

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

16. 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 clients legs.

d.

position the client upright.

ANS: B

Reflex spasms may be triggered by extrinsic or visceral stimuli, such as a distended bladder. In a client with a new spinal cord injury or for whom spasms are new, the nurse would do best to try to assess for a causative factor before just medicating the client. Antispasmodic medications would be more helpful than pain medications. Massaging the legs is never a good idea because of the theoretical risk of dislodging a DVT. Positioning the client will not assist with muscle spasms.

DIF: Analysis/Analyzing REF: p. 1952 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Alteration in Body Systems

17. 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.

ANS: C

In the emergency department a person who has sustained a severe cervical injury should be placed immediately in skeletal traction to immobilize the cervical spine and reduce the fracture and dislocation. Gardner-Wells tongs are an example of cervical traction.

DIF: Comprehension/Understanding REF: p. 1955 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Medical Emergencies

18. 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.

ANS: A

The bowel movements of clients with upper motor neuron damage are generally regulated with suppositories or digital stimulation every day or every other day to limit the risk of autonomic dysreflexia.i

DIF: Application/Applying REF: p. 1961 OBJ: Intervention

MSC: Physiological Integrity Basic Care and Comfort-Elimination

19. 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 clients urinalysis.

d.

placing an indwelling Foley catheter.

ANS: A

Clients with spinal cord injuries are prone to many urinary complications. Nurses should encourage the client to drink at least 3000 ml/day, performing intermittent catheterization or voiding every 4-6 hours, and by the nurse assessing the clients bladder emptying with a post void residual.

DIF: Application/Applying REF: p. 1965 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

20. 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.

ANS: C

People with a C5 transection will be able to dress the upper trunk, propel a wheelchair after rehabilitative surgery, learn to type or write, and assist with getting in and out of bed.

DIF: Application/Applying REF: p. 1959 OBJ: Intervention

MSC: Physiological Integrity Physiological Adaptation-Pathophysiology Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

21. 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.

ANS: C

Sexuality is an important aspect of caring for a client with a spinal cord injury. A penile implant is one avenue to continuation of sexual activity; however, the nurse must remember that sexual activity in spinal cordinjured men depends in large part on the location of the injury.

DIF: Comprehension/Understanding REF: p. 1961 OBJ: Intervention

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Human Sexuality

22. While caring for a spinal cordinjured 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.

ANS: C

If autonomic dysreflexia does occur, elevate the head of the bed to a sitting position immediately, check the blood pressure, check for possible sources of irritation, remove the stimulus if it can be done quickly, administer antihypertensive medications per order, if needed, and notify the physician.

DIF: Application/Applying REF: p. 1966 OBJ: Intervention

MSC: Safe, Effective Care Environment Management of Care-Establishing Priorities

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.

ANS: C

To prevent further injury to the client with a suspected spinal cord injury, the nurse (and other members of the health care team) should logroll the client. Mannitol is used for increased intracranial pressure. A tetanus booster may or may not be indicated, depending on if any skin was broken. While a thorough history is important, client safety is paramount.

DIF: Application/Applying REF: p. 1954 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Injury Prevention

24. 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.

ANS: C

Weight-bearing stimulates osteoblastic activity and thus decreases the demineralization of bone that develops with prolonged immobilization.

DIF: Comprehension/Understanding REF: p. 1963 OBJ: Intervention

MSC: Health Promotion and Maintenance Prevention and/or Early Detection of Health Problems-Disease Prevention

25. The nurse is caring for a spinal cordinjured 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.

ANS: A

Option a is the best indicator that goals for this diagnosis have been met. The other options all show some improvement or movement in the right direction, but option a is a much more comprehensive outcome.

DIF: Evaluation/Evaluating REF: p. 1967 OBJ: Evaluation

MSC: Psychosocial Integrity Coping and Adaptation-Grief and Loss

MULTIPLE RESPONSE

1. 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 drivers 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.

ANS: A, C, D, E

Many factors make caring for the elderly client with head injury more challenging. Besides options a, c, d, and e, the presence of chronic diseases may make managing ventilation and fluid balance more difficult. Medical complications may impede recovery and cardiac dysrhythmias are less tolerated. Head injury from auto accidents is not as common as in the younger population but often occurs from falls.

DIF: Knowledge/Remembering REF: p. 1948 OBJ: Intervention

MSC: Health Promotion and Maintenance Growth and Development Through the Lifespan-Age Related Differences

2. 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.

ANS: A, B, D

Intracranial monitors all carry a high risk of infection, and because of their placement an infection has serious consequences. Interventions to minimize the risk of infection include options a, b, and d. The monitoring system is manipulated as little as possible and left in for the shortest amount of time possible.

DIF: Application/Applying REF: p. 1927 OBJ: Intervention

MSC: Safe, Effective Care Environment Safety and Infection Control-Medical and Surgical Asepsis

3. 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

ANS: A, B, C, D, E

Interdisciplinary techniques of rehabilitation incorporating all the above options, plus compensatory techniques and physical fitness, have the best results and the best chance to lead to the TBI client living a satisfying and productive life.

DIF: Comprehension/Understanding REF: p. 1948 OBJ: Intervention

MSC: Psychosocial Integrity Psychosocial Adaptation-Quality of Life

Elsevier items and derived items 2009 by Saunders, an imprint of Elsevier Inc.

Some material was previously published.

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