Chapter 23: Care of Patients with Head and Spinal Cord Injuries My Nursing Test Banks

Chapter 23: Care of Patients with Head and Spinal Cord Injuries

MULTIPLE CHOICE

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

a.

the brain tissue is bruised.

b.

no loss of consciousness occurs.

c.

there is amnesia related to the incident.

d.

there are no subsequent symptoms.

ANS: C

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.

DIF: Cognitive Level: Comprehension REF: 500 OBJ: 1 (theory)

TOP: Concussion: Pathophysiology KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

2. 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:

a.

a smaller brain, which allows for more movement inside the cranium.

b.

fragile vessels more likely to rupture.

c.

less cerebrospinal fluid to cushion the brain.

d.

less flexibility of the meninges to absorb impact.

ANS: A

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

DIF: Cognitive Level: Comprehension REF: 501 | Elder Care Points

OBJ: 6 (theory) TOP: Cranial Bleed: Older Adult

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

a.

Document the presence of rhinorrhea.

b.

Inform the physician of the assessment.

c.

Test fluid with a glucose Accu-Chek or Dextrostix.

d.

Tape a drip pad under the nose.

ANS: C

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.

DIF: Cognitive Level: Application REF: 502 OBJ: 1 (theory)

TOP: Rhinorrhea KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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

a.

Left-sided motor deficit with sluggish right pupil response

b.

Right-sided motor deficit with brisk right pupil response

c.

Bilateral motor deficit with bilaterally sluggish pupil response

d.

Left-sided motor deficit and bilateral PERRLA

ANS: A

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

DIF: Cognitive Level: Application REF: 502 OBJ: 2 (theory)

TOP: Closed Head Injury: Assessment KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

5. 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?

a.

Increasing respiratory rate

b.

Decreasing heart rate

c.

Decreasing pulse pressure

d.

Decreasing level of consciousness (LOC)

ANS: D

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.

DIF: Cognitive Level: Application REF: 501 | Elder Care Points

OBJ: 2 (theory) TOP: Epidural Hematoma: Signs

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

6. 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?

a.

Ensure effectiveness of the drug.

b.

Avoid fluid overload.

c.

Maintain electrolyte balance.

d.

Maintain adequate blood pressure.

ANS: B

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

DIF: Cognitive Level: Application REF: 507 OBJ: 3 (theory)

TOP: Diuretic Drip: Mannitol KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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

a.

Elevate the head of the bed 30 to 45 degrees.

b.

Place drip pad or cotton to absorb cerebrospinal fluid drainage from the nose or ears.

c.

Keep the patient stimulated to better assess changing level of consciousness.

d.

Allow the patient to change positions frequently for comfort.

ANS: A

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

DIF: Cognitive Level: Application REF: 503 OBJ: 2 (theory)

TOP: Cranial Surgery: Postoperative Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

8. The unconscious patient with a closed head injury is on mechanical ventilation. To improve brain perfusion through increased blood pressure, the CO2 level is maintained at _____ mm Hg.

a.

10 to 15

b.

15 to 20

c.

20 to 25

d.

25 to 30

ANS: D

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.

DIF: Cognitive Level: Comprehension REF: 507-508 OBJ: 4 (theory)

TOP: Carbon Dioxide Level on Mechanical Ventilation

KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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

a.

lethargy.

b.

pulse pressure.

c.

urinary output.

d.

blood glucose levels.

ANS: C

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.

DIF: Cognitive Level: Application REF: 508 OBJ: 1 (theory)

TOP: Development of Diabetes Insipidus

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

a.

high Fowlers.

b.

right side-lying.

c.

flat with small pillow under head.

d.

head of bed 20 to 30 degrees.

ANS: D

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.

DIF: Cognitive Level: Comprehension REF: 503 OBJ: 4 (theory)

TOP: Closed Head Injury: Positioning KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

11. 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?

a.

Alert

b.

Confused

c.

Lethargic

d.

Obtunded

ANS: B

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.

DIF: Cognitive Level: Application REF: 502 | Box 23-1

OBJ: 2 (clinical) TOP: LOC Discrimination

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

12. 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?

a.

Motor function sometimes returns after the edema of the spinal cord has subsided.

b.

Motor function may improve, but there will always be a deficit.

c.

In all likelihood the paralysis will be permanent.

d.

The physician is the best source for that information.

ANS: A

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.

DIF: Cognitive Level: Application REF: 510 OBJ: 7 (theory)

TOP: Spinal Cord Edema KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

13. 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:

a.

increased intracranial pressure.

b.

increased edema of the cord.

c.

return of voluntary motor activity.

d.

muscle spasms.

ANS: D

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.

DIF: Cognitive Level: Application REF: 513-514 OBJ: 8 (theory)

TOP: SCI Patient: Muscle Spasms KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

a.

grasp the muscle firmly when moving the patient.

b.

use palms of hands to support joints when moving the patient.

c.

log roll the patient as a unit.

d.

perform passive range of motion (ROM).

ANS: B

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

DIF: Cognitive Level: Application REF: 513-514 OBJ: 8 (theory)

TOP: Muscle Spasm: Prevention KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Basic Care and Comfort

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

a.

elevate the head of the bed to lower blood pressure.

b.

notify the charge nurse to get assistance.

c.

increase IV fluid rate to ensure adequate circulating volume.

d.

administer anti-hypertensive medication.

ANS: A

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.

DIF: Cognitive Level: Application REF: 514-515 OBJ: 8 (theory)

TOP: Autonomic Dysreflexia: Intervention

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

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

a.

turn the patient as a unit by log rolling.

b.

release the weights to prevent injury while turning.

c.

turn quickly to avoid muscle spasms.

d.

advise the patient to hold his breath and bear down during turning.

ANS: A

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.

DIF: Cognitive Level: Application REF: 516 OBJ: 8 (theory)

TOP: Crutchfield Tongs: Turning KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

17. 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?

a.

Herniated disk

b.

Muscle spasm in lower back

c.

Spinal cord injury

d.

Sciatica

ANS: A

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.

DIF: Cognitive Level: Comprehension REF: 518 OBJ: 9 (theory)

TOP: Herniated Disk: Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

18. 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?

a.

Keep the halo jacket fastened unless the patient is in a supine position.

b.

Monitor the bladder every 4 hours for signs of bladder distention.

c.

Instruct unlicensed assistive personnel (UAP) to turn and reposition the patient every 2 hours.

d.

Assess compression stockings for proper fit.

ANS: C

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.

DIF: Cognitive Level: Analysis REF: 516 | Assignment Considerations

OBJ: 3 (clinical) TOP: Spinal Cord Injury Care

KEY: Nursing Process Step: Planning

MSC: NCLEX: Safe, Effective Care Environment: Management of Care

MULTIPLE RESPONSE

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

a.

allowing the brain to twist on the brainstem.

b.

moving forward to strike the anterior interior skull.

c.

allowing the brain to compress on itself.

d.

striking the bony area opposite the site of impact.

e.

losing small amounts of cerebrospinal fluid.

ANS: B, D

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.

DIF: Cognitive Level: Application REF: 501 | Figure 23-1

OBJ: 1 (theory) TOP: Coup-Contrecoup: Pathophysiology

KEY: Nursing Process Step: Implementation

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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

a.

Increasing irritability

b.

Complaint of a dull headache

c.

Frequent nodding off in chair during the day

d.

Focal seizures

e.

Staggering gait

ANS: A, B, C

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.

DIF: Cognitive Level: Application REF: 501-502 OBJ: 2 (theory)

TOP: Subdural Hematoma: Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Health Promotion and Maintenance: Prevention and Early Detection of Disease

21. The nurse documents all the signs of epidural hematoma in a patient with a closed head injury, which are: (Select all that apply.)

a.

mottling of extremities.

b.

periorbital ecchymosis.

c.

Battles sign.

d.

nausea and vomiting.

e.

PERRLA.

ANS: B, C, D

Raccoon eyes (periorbital ecchymosis), bruising behind the ears, and nausea and vomiting are some of the typical signs of epidural hematoma.

DIF: Cognitive Level: Comprehension REF: 501-502 OBJ: 2 (theory)

TOP: Epidural Hematoma: Signs KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

22. The nurse is aware that an epidural hematoma warrants immediate intervention based on which criteria? (Select all that apply.)

a.

An epidural hematoma is related to bleeding from arterial venous source.

b.

An epidural hematoma can increase intracranial pressure quickly.

c.

An epidural hematoma changes overall condition quickly.

d.

An epidural hematoma can cause death.

e.

An epidural hematoma can cause irreversible brain damage.

ANS: B, C, D, E

Bleeding is related to an arterial source. All other options are the complications of an epidural hematoma. An epidural hematoma is a medical emergency.

DIF: Cognitive Level: Application REF: 500-501 OBJ: 2 (theory)

TOP: Epidural Hematoma: Complications

KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

23. The nurse is caring for a patient who has a complete transection of the cord at C7. The patient asks the nurse what functions he will be able to perform. The nurse responds that the patient will most likely be able to perform which activities? (Select all that apply.)

a.

Transferring himself

b.

Dressing himself

c.

Using a wheelchair with standard hand rims

d.

Feeding himself

e.

Effectively typing using all digits

ANS: A, B, C, D

The patient with an injury at C7 does not have full control of all digits. The third finger is the most functional. With physical and occupational therapy, the patient may be able to perform all other functions listed.

DIF: Cognitive Level: Analysis REF: 511 | Table 23-1

OBJ: 8 (theory) TOP: Cord Injury: C7

KEY: Nursing Process Step: Planning MSC: NCLEX: Health Promotion and Maintenance

24. The nurse caring for a patient with autonomic dysreflexia assesses the patient for which conditions or situations? (Select all that apply.)

a.

Distended bladder

b.

Constipation

c.

Increased fluid intake

d.

Wrinkles in bed linens

e.

Abrupt environmental temperature changes

ANS: A, B, D, E

Bladder distention, constipation, wrinkled bed linens, and temperature changes are potential triggers for autonomic dysreflexia (AD) that the nurse should assess for. This condition causes a rapid increase in blood pressure.

DIF: Cognitive Level: Application REF: 514-515 OBJ: 8 (theory)

TOP: Autonomic Dysreflexia: Etiology KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential

25. The nurse is evaluating the patient to determine if adequate learning has occurred regarding care of lower back pain. The nurse determines no further teaching is required when observing which patient activities? (Select all that apply.)

a.

The patient carries items away from the center of the body.

b.

The patient bends the knees, with the back straight, and crouches to lift an item off the floor.

c.

The patient uses a lumbar pillow or roll when sitting for long periods.

d.

The patient performs proper back exercises twice a day.

e.

The patient maintains proper body weight.

ANS: B, C, D, E

The patient should carry items close to the center of the body rather than away from the center of the body. All other options demonstrated correct care of the lower back.

DIF: Cognitive Level: Application REF: 520 | Patient Teaching

OBJ: 4 (clinical) TOP: Low Back Pain: Self-Care Measures

KEY: Nursing Process Step: Evaluation MSC: NCLEX: Health Promotion and Maintenance

COMPLETION

26. The nurse is aware that increasing intracranial pressure can cause _____________ of the brain, which results in the brain impinging on the brainstem.

ANS:

herniation

When the brain is under unreduced pressure, it can herniate through the notch of the tentorium and impinge on the brainstem.

DIF: Cognitive Level: Knowledge REF: 506 OBJ: 5 (theory)

TOP: Herniation: Etiology KEY: Nursing Process Step: Assessment

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

27. If conservative measures are unsuccessful in treating a herniated disc, a(n) __________ may be necessary to remove the posterior arch of the vertebra, along with the disk.

ANS:

diskectomy

laminectomy

A diskectomy or laminectomy is performed to decompress the nerve root when other, less invasive, methods of treatment are not successful.

DIF: Cognitive Level: Comprehension REF: 518-519 OBJ: 9 (theory)

TOP: Herniated Disk KEY: Nursing Process Step: Planning

MSC: NCLEX: Physiological Integrity: Physiological Adaptation

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