ch 63 neurologic trauma Flashcards
(40 cards)
the emergency room nurse is caring for a client who has been brought in by ambulance after sustaining a fall at home. what physical assessment findings are suggestive of a basilar skull fracture? select all that apply
-epistaxis
-bruising over the mastoid
a client is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1.5 hours ago. endotracheal intubation has been deemed necessary and the nurse is preparing to assist. what nursing diagnosis should the nurse associate with this procedure?
risk for injury
a nurse is caring for a critically ill client with autonomic dysreflexia. What clinical manifestations would the nurse expect in this client?
bradycardia and hypertension
the nurse is caring for a client with increased intracranial pressure caused by a traumatic brain injury. which of the following clinical manifestations would suggest that the client may be experiencing increased brain compression causing brain stem damage?
hyperthermia
a client is brought to the ed after falling off a rood. the care team suspects an epidural hematoma, prompting the nurse to anticipate for which priority intervention?
making openings in the skull
the staff educator is precepting a nurse new to the critical care unit when a clint with a T2 spinal cord injury is admitted. the client is soon exhibiting manifestations of neurogenic shock. in addition to monitoring the client closely, what would be the nurse’s most appropriate action?
prepare for interventions to increase the client’s BP
an ED nurse has just received a call from EMS that they are transporting a 17 year old client who has just sustained a spinal cord injury. the nurse recognizes that the most common cause of this type of injury is what event?
motor vehicle accidents
a nurse has a client with a spinal cord injury and is tailoring their care plan to prevent the major causes of death for this client. teh nurse’s care plan includes assisted coughing techniques, a sequential compression device, and prevention of pressure injuries. which are the most likely possible cause of death for this client?
pneumonia, pulmonary embolism, and sepsis
paramedics have brought an intubated client to the RD following a head injury due to acceleration-deceleration motor vehicle accident. Increased ICP is suspected. appropriate nursing interventions would include which of the following?
administer benzodiazepines on a PRN basis
a client who has sustained a non depressed skull fracture is admitted to the acute medical unit. nursing care should include which of the following?
watchful waiting and close monitoring
a client who suffered a spinal cord injury is experiencing an exaggerated autonomic response. What aspect of the client’s current health status is most likely to have precipitated this event?
the client’s urinary catheter became occluded
a 35 year old client is being admitted to the ICU for increased observation with a brain injury and is awake, alert, and disoriented to time and situation. the client sustained a fall from a roof, and x rays are pending. the nurse would anticipate which supportive priority measures for this client?
cervical and spinal immobilization
a client with a head injury has been increasingly agitated and the nurse has consequently identified a risk for injury. what is the nurses best intervention for preventing injury?
pad the side rails of the client’s bed
a client with a C5 spinal cord injury has tetraplegia. after being moved out of the ICU, the client reports a severe throbbing headache. what should the nurse do first?
check the client’s indwelling urinary catheter for kinks to ensure patency
a client is admitted to the neurologic ICU with a spinal cord injury. when assessing the client the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. what should the nurse suspect?
spinal shock
a client sustained a head injury as a result of trauma. the health care provider has instituted seizure prophylactic measures. The nurse anticipates which specific measures begin initiated for this client?
anticonvulsant medications on day two of injury
the nurse is assessing a client with a spinal cord injury that reports a severe headache with a rapid onset. the nurse knows that this could be a symptom of which complication of a spinal cord injury?
autonomic dysreflexia
a nurse is reviewing the trend of a clients scores on the glasgow coma scale. this provides what potential information to the nurse about the client’s status?
an assessment of the client’s current level of consciousness
the nurse is caring for a client who is rapidly progressing toward brain death. the nurse should be aware of what cardinal signs of brain death? select all that apply.
-apnea
-coma
-absence of brain stem reflexes
following a spinal cord injury, a client is placed in halo traction. while performing pin site care, the nurse notes that one of the traction pins has become detached. the nurse would be correct in implementing what priority nursing action?
notify the neurosurgeon of the occurrence
the ed is notified that a 6 year old is in transit with a suspected brain injury after being struck by a car. the child is unresponsive at this time, but vital signs are within acceptable limits. what will be the primary goal of initial therapy?
preserving brain homeostasis
a client is admitted to the neurologic ICU with a a suspected diffuse axonal injury. which primary neuroimaging diagnostic tool would be used on this client to evaluate the brain structure?
MRI
a 13 year old was brought to the ER after being hit in the head with a baseball and is subsequently diagnosed with a concussion. which assessment finding would rule out discharging the client?
the client’s speech is slightly slurred
an 82 year old client is admitted for observation after a fall. due to the client’s age, the nurse knows that the client is at increased risk for what complication of this injury?
hematoma
