Chapter 68: Management of Patients with Neurologic Trauma
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Course
Neurology
Institution
Neurology
Chapter 68: Management of Patients with Neurologic Trauma 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 o...
Chapter 68: Management of Patients with Neurologic
Trauma
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?
Monitoring is needed as rapid neurologic deterioration may occur.
A patient with a C7 spinal cord fracture informs the nurse, "My head is killing me!" The
nurse assesses a blood pressure of 210/140 mm Hg, heart rate of 48 and observes
diaphoresis on the face. What is the first action by the nurse?
Place the patient in a sitting position.
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?
The client has cerebral spinal fluid (CSF) leaking from the ear.
Which of the following types of hematoma results from venous bleeding with blood
gradually accumulating in the space below the dura?
Subdural
Autonomic dysreflexia can occur with spinal cord injuries above which of the following
levels?
T6
When caring for a client who is post-intracranial surgery what is the most important
parameter to monitor?
Body temperature
When the nurse observes that the patient has extension and external rotation of the
arms and wrists, and extension, plantar flexion, and internal rotation of the feet, she
records the patient's posturing as which of the following?
Decerebrate
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?
Autonomic dysreflexia
The most important nursing priority of treatment for a patient with an altered LOC is to:
Maintain a clear airway to ensure adequate ventilation.
, A client with a spinal cord injury is to receive methylprednisolone sodium succinate 100
mg intravenously twice a day. The medication is supplied in vials containing 125 mg per
2 mL. How many mL will constitute the correct dose? Enter the correct number ONLY.
1.6
Explanation:
(100 mg/125 mg) x 2 mL = 1.6 mL.
The nurse is caring for a patient diagnosed with an acute subdural hematoma following
a craniotomy. The nurse is preparing to administer an IV dose of dexamethasone
(Decadron). The medication is available in a 20-mL IV bag and ordered to be infused
over 15 minutes. At what rate (mL/hr) will the nurse set the infusion pump?
80 mL/hr
Explanation:
20/15 × 60 = 80 mL/hr
Which of the following is the earliest sign of increasing intracranial pressure (ICP)?
Change in level of consciousness (LOC)
The nurse is caring for a patient following an SCI who has a halo device in place. The
patient is preparing for discharge. Which of the following statements made by the
patient indicates the need for further instruction?
"I can apply powder under the liner to help with sweating."
A 65-year-old client was hit in the head with a ball and was knocked unconscious. Upon
her arrival at the emergency department and subsequent diagnostic tests, it was
determined that she suffered a subdural hematoma. The client is becoming increasingly
symptomatic. How would you expect her subdural hematoma to be classified?
Acute
The nurse is conducting a health fair on spinal cord injury (SCI) at a local high school.
The nurse relays that which of the following is the most common cause of SCI?
Motor vehicle crashes
The nurse is offering suggestions regarding reproductive options to a husband and
paraplegic wife. Which option is most helpful?
Conception is not impaired; the birth process is determined with the physician.
The nurse reviews the physician's emergency department progress notes for the patient
who has sustained a head injury and sees that the physician observed Battle's sign. The
nurse knows that the physician observed which clinical manifestation?
An area of bruising over the mastoid bone
A client admitted with a cerebral contusion is confused, disoriented, and restless. Which
nursing diagnosis takes the highest priority?
Risk for injury related to neurologic deficit
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