1) An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
- Reposition the client to avoid neck flexion
- Administer 1 g Mannitol IV as ordered
- Increase the ventilator’s respiratory rate to 20 breaths/minute
- Administer 100mg of pentobarbital IV as ordered.
2) A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
- Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
- Rapid dilantin administration can cause cardiac arrhythmias.
- Dilantin should be mixed in dextrose in water before administration.
- Dilantin should be administered through an IV catheter in the client’s hand.
3) A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
- Evaluate urine specific gravity
- Anticipate treatment for renal failure
- Provide emollients to the skin to prevent breakdown
- Slow down the IV fluids and notify the physician
4) When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
- Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
- Emergent; the client is poorly oxygenated.
- Significant; the client has alveolar hypoventilation.
5) A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?
- Bloody drainage from the ears
- Frequent swallowing
- Guaiac-positive stools
6) After a hypophysectomy, vasopressin is given IM for which of the following reasons?
- To treat growth failure
- To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
- To reduce cerebral edema and lower intracranial pressure
- To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
7) A client comes into the ER after hitting his head in an MVA. He’s alert and oriented. Which of the following nursing interventions should be done first?
- Assess full ROM to determine extent of injuries
- Call for an immediate chest x-ray
- Immobilize the client’s head and neck
- Open the airway with the head-tilt chin-lift maneuver
8) A client with a C6 spinal injury would most likely have which of the following symptoms?
9) A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
- Bladder distension
- Neurological deficit
- Pulse ox readings
- The client’s feelings about the injury
10) While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?
- Autonomic dysreflexia
- Hemorrhagic shock
- Neurogenic shock
- Pulmonary embolism
11) A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
- Acetazolamide (Diamox)
- Furosemide (Lasix)
- Methylprednisolone (Solu-Medrol)
- Sodium bicarbonate
12) A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
- Place the client flat in bed
- Assess patency of the indwelling urinary catheter
- Give one SL nitroglycerin tablet
- Raise the head of the bed immediately to 90 degrees
13) A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
- To hasten wound healing
- To immobilize the surgical spine
- To prevent autonomic dysreflexia
- To hold bony fragments of the skull together
14) Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?
- Insert an indwelling urinary catheter to straight drainage
- Schedule intermittent catherization every 2 to 4 hours
- Perform a straight catherization every 8 hours while awake
- Perform Crede’s maneuver to the lower abdomen before the client voids.
15) A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
- Laceration of the middle meningeal artery
- Rupture of the carotid artery
- Thromboembolism from a carotid artery
- Venous bleeding from the arachnoid space
16) A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
- Position the client flat in bed
- Check the fluid for dextrose with a dipstick
- Suction the nose to maintain airway patency
- Insert nasal and ear packing with sterile gauze
17) When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?
- An interval when the client’s speech is garbled
- An interval when the client is alert but can’t recall recent events
- An interval when the client is oriented but then becomes somnolent
- An interval when the client has a “warning” symptom, such as an odor or visual disturbance.
18) Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
- A client with a brain injury
- A client with a herniated nucleus pulposus
- A client with a high cervical spine injury
- A client with a stroke
19) Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?
- Absence of pain sensation in chest
- Spontaneous respirations
- Urinary continence
20) A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
- Lumbar spinal cord injury
- Neurogenic shock
- Noxious stimuli
21) During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
- Elevate the client’s legs
- Put the client flat in bed
- Put the client in the Trendelenburg’s position
- Put the client in the high-Fowler’s position
22) A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?
- Autonomic dysreflexia
- Neurogenic shock
23) A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?
- Absent corneal reflex
- Decerebate posturing
- Movement of only the right or left half of the body
- The need for mechanical ventilation
24) A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?
- Decreased urine output or oliguria
- Hypertension and bradycardia
- Respiratory depression
- Symptoms of shock
25) A 40-year-old paraplegic must perform intermittent catherization of the bladder. Which of the following instructions should be given?
- “Clean the meatus from back to front.”
- “Measure the quantity of urine.”
- “Gently rotate the catheter during removal.”
- “Clean the meatus with soap and water.”
26) An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?
- “Watch him for keyhole pupil the next 24 hours.”
- “Expect profuse vomiting for 24 hours after the injury.”
- “Wake him every hour and assess his orientation to person, time, and place.”
- “Notify the physician immediately if he has a headache.”
27) Which neurotransmitter is responsible for may of the functions of the frontal lobe?
28) The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
- Extent of intracranial bleeding
- Sites of brain injury
- Activity of the brain
- Percent of functional brain tissue
29) A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
- Subdural hematoma
- Subarachnoid hemorrhage
- Epidural hematoma
30) After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?
- Quadriplegia with gross arm movement and diaphragmic breathing
- Quadriplegia and loss of respiratory function
- Paraplegia with intercostal muscle loss
- Loss of bowel and bladder control
31) A 20-year-old client who fell approximately 30’ is unresponsive and breathless. A cervical spine injury is suspected. How should the first-responder open the client’s airway for rescue breathing?
- By inserting a nasopharyngeal airway
- By inserting a oropharyngeal airway
- By performing a jaw-thrust maneuver
- By performing the head-tilt, chin-lift maneuver
32) The nurse is caring for a client with a T5 complete spinal cord injury. Upon assessment, the nurse notes flushed skin, diaphoresis above the T5, and a blood pressure of 162/96. The client reports a severe, pounding headache. Which of the following nursing interventions would be appropriate for this client? Select all that apply.
- Elevate the HOB to 90 degrees
- Loosen constrictive clothing
- Use a fan to reduce diaphoresis
- Assess for bladder distention and bowel impaction
- Administer antihypertensive medication
- Place the client in a supine position with legs elevated
33) The client with a head injury has been urinating copious amounts of dilute urine through the Foley catheter. The client’s urine output for the previous shift was 3000 ml. The nurse implements a new physician order to administer:
- Desmopressin (DDAVP, stimate)
- Dexamethasone (Decadron)
- Ethacrynic acid (Edecrin)
- Mannitol (Osmitrol)
34) The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with:
- Skull fracture
- Subdural hematoma
- Epidural hematoma
35) The nurse is caring for a client who suffered a spinal cord injury 48 hours ago. The nurse monitors for GI complications by assessing for:
- A flattened abdomen
- Hematest positive nasogastric tube drainage
- Hyperactive bowel sounds
- A history of diarrhea
36) A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
- Strict adherence to a bowel retraining program
- Limiting bladder catherization to once every 12 hours
- Keeping the linen wrinkle-free under the client
- Preventing unnecessary pressure on the lower limbs
37) The nurse is planning care for the client in spinal shock. Which of the following actions would be least helpful in minimizing the effects of vasodilation below the level of the injury?
- Monitoring vital signs before and during position changes
- Using vasopressor medications as prescribed
- Moving the client quickly as one unit
- Applying Teds or compression stockings.
38) The nurse is caring for a client admitted with spinal cord injury. The nurse minimizes the risk of compounding the injury most effectively by:
- Keeping the client on a stretcher
- Logrolling the client on a firm mattress
- Logrolling the client on a soft mattress
- Placing the client on a Stryker frame
39) The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
- Positive reflexes
- Inability to elicit a Babinski’s reflex
- Reflex emptying of the bladder
40) A client with a spinal cord injury suddenly experiences an episode of autonomic dysreflexia. After checking the client’s vital signs, list in order of priority, the nurse’s actions (Number 1 being the first priority and number 5 being the last priority).
- Check for bladder distention
- Raise the head of the bed
- Contact the physician
- Loosen tight clothing on the client
- Administer an antihypertensive medication
41) A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
- Unequal pupil size
- Decreasing systolic blood pressure
- Decreasing body temperature
42) Which of the following respiratory patterns indicate increasing ICP in the brain stem?
- Slow, irregular respirations
- Rapid, shallow respirations
- Asymmetric chest expansion
- Nasal flaring
43) Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
- Give the client a warming blanket
- Administer low-dose barbiturate
- Encourage the client to hyperventilate
- Restrict fluids
44) A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client’s condition?
- Widening pulse pressure
- Decrease in the pulse rate
- Dilated, fixed pupil
- Decrease in LOC
45) A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
- Place her in a jacket restraint
- Wrap her hands in soft “mitten” restraints
- Tuck her arms and hands under the draw sheet
- Apply a wrist restraint to each arm
46) Which of the following describes decerebrate posturing?
- Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers
- Back hunched over, rigid flexion of all four extremities with supination of arms and plantar flexion of the feet
- Supination of arms, dorsiflexion of feet
- Back arched; rigid extension of all four extremities.
47) A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
- Count the rate to be sure the ventilations are deep enough to be sufficient
- Call the physician while another nurse checks the vital signs and ascertains the patient’s Glasgow Coma score.
- Call the physician to adjust the ventilator settings.
- Check deep tendon reflexes to determine the best motor response
48) In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy, which of the following is contraindicates when positioning the client?
- Keeping the client flat on one side or the other
- Elevating the head of the bed to 30 degrees
- Log rolling or turning as a unit when turning
- Keeping the head in neutral position
49) A client has been pronounced brain dead. Which findings would the nurse assess? Check all that apply.
- Decerebrate posturing
- Dilated non reactive pupils
- Deep tendon reflexes
- Absent corneal reflex
50) Shortly after admission to an acute care facility, a male client with a seizure disorder develops status epilepticus. The physician orders diazepam (Valium) 10 mg I.V. stat. How soon can the nurse administer a second dose of diazepam, if needed and prescribed?
- In 30 to 45 seconds
- In 10 to 15 minutes
- In 30 to 45 minutes
- In 1 to 2 hours
Answers and Rationales
- A. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy.
- B. Dilantin IV shouldn’t be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldn’t be mixed in solution for administration. However, because it’s compatible with normal saline solution, it can be injected through an IV line containing normal saline. When given through an IV catheter hand, dilantin may cause purple glove syndrome.
- A. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There’s no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn’t need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.
- A. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.
- B. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture.
- D. After hypophysectomy, or removal of the pituitary gland, the body can’t synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema.
- C. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesn’t need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldn’t be used until the cervical spine injury is ruled out.
- D. Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below.
- C. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority.
- C. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldn’t be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.
- C. High doses of Solu-Medrol are used within 24 hours of spinal injury to reduce cord swelling and limit neurological deficit. The other drugs aren’t indicated in this circumstance.
- D. Anxiety, flushing above the level of the lesion, piloerection, hypertension, and bradycardia are symptoms of autonomic dysreflexia, typically caused by such noxious stimuli such as a full bladder, fecal impaction, or decubitus ulcer. Putting the client flat will cause the blood pressure to increase even more. The indwelling urinary catheter should be assessed immediately after the HOB is raised. Nitroglycerin is given to reduce chest pain and reduce preload; it isn’t used for hypertension or dysreflexia.
- B. Gardner-Wells, Vinke, and Crutchfield tongs immobilize the spine until surgical stabilization is accomplished.
- B. Intermittent catherization should begin every 2 to 4 hours early in the treatment. When residual volume is less than 400 ml, the schedule may advance to every 4 to 6 hours. Indwelling catheters may predispose the client to infection and are removed as soon as possible. Crede’s maneuver is not used on people with spinal cord injury.
- A. Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma.
- B. Clear fluid from the nose or ear can be determined to be cerebral spinal fluid or mucous by the presence of dextrose. Placing the client flat in bed may increase ICP and promote pulmonary aspiration. The nose wouldn’t be suctioned because of the risk for suctioning brain tissue through the sinuses. Nothing is inserted into the ears or nose of a client with a skull fracture because of the risk of infection.
- C. A lucid interval is described as a brief period of unconsciousness followed by alertness; after several hours, the client again loses consciousness. Garbled speech is known as dysarthria. An interval in which the client is alert but can’t recall recent events is known as amnesia. Warning symptoms or auras typically occur before seizures.
- C. Autonomic dysreflexia refers to uninhibited sympathetic outflow in clients with spinal cord injuries about the level of T10. The other clients aren’t prone to dysreflexia.
- C. Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn’t apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.
- D. Noxious stimuli, such as a full bladder, fecal impaction, or a decub ulcer, may cause autonomic dysreflexia. A headache is a symptom of autonomic dysreflexia, not a cause. Autonomic dysreflexia is most commonly seen with injuries at T10 or above. Neurogenic shock isn’t a cause of dysreflexia.
- D. Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension. Elevating the client’s legs, putting the client flat in bed, or putting the bed in the Trendelenburg’s position places the client in positions that improve cerebral blood flow, worsening hypertension.
- C. Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock. Hypervolemia is indicated by rapid and bounding pulse and edema. Autonomic dysreflexia occurs after neurogenic shock abates. Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.
- D. The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time. Absent corneal reflexes, decerebate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.
- B. Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.
- D. Intermittent catherization may be performed chronically with clean technique, using soap and water to clean the urinary meatus. The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man. It isn’t necessary to measure the urine. The catheter doesn’t need to be rotated during removal.
- C. Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are assessed frequently for 24 hours. A keyhole pupil is found after iridectomy. Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately. A slight headache may last for several days after concussion; severe or worsening headaches should be reported.
- A. The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it’s such an important neurotransmitter in schizophrenia.
- C. An EEG measures the electrical activity of the brain. Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI. Percent of functional brain tissue would be determined by a series of tests.
- C. An epidural hematoma occurs when blood collects between the skull and the dura mater. In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater. In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane. A contusion is a bruise on the brain’s surface.
- A. A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmic breathing. Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function. Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2. Injuries below L2 cause paraplegia and loss of bowel and bladder control.
- C. If the client has a suspected cervical spine injury, a jaw-thrust maneuver should be used to open the airway. If the tongue or relaxed throat muscles are obstructing the airway, a nasopharyngeal or oropharyngeal airway can be inserted; however, the client must have spontaneous respirations when the airway is open. The head-tilt, chin-lift maneuver requires neck hyperextension, which can worsen the cervical spine injury.
- A, B, D, E. The client has signs and symptoms of autonomic dysreflexia. The potentially life-threatening condition is caused by an uninhibited response from the sympathetic nervous system resulting from a lack of control over the autonomic nervous system. The nurse should immediately elevate the HOB to 90 degrees and place extremities dependently to decrease venous return to the heart and increase venous return from the brain. Because tactile stimuli can trigger autonomic dysreflexia, any constrictive clothing should be loosened. The nurse should also assess for distended bladder and bowel impaction, which may trigger autonomic dysreflexia, and correct any problems. Elevated blood pressure is the most life-threatening complication of autonomic dysreflexia because it can cause stroke, MI, or seizures. If removing the triggering event doesn’t reduce the client’s blood pressure, IV antihypertensives should be administered. A fan shouldn’t be used because cold drafts may trigger autonomic dysreflexia.
- A. A complication of a head injury is diabetes insipidus, which can occur with insult to the hypothalamus, the antidiuretic storage vesicles, or the posterior pituitary gland. Urine output that exceeds 9 L per day generally requires treatment with desmopressin. Dexamethasone, a glucocorticoid, is administered to treat cerebral edema. This medication may be ordered for the head injured patient. Ethacrynic acid and mannitol are diuretics, which would be contraindicated.
- D. The changes in neurological signs from an epidural hematoma begin with a loss of consciousness as arterial blood collects in the epidural space and exerts pressure. The client regains consciousness as the cerebral spinal fluid is reabsorbed rapidly to compensate for the rising intracranial pressure. As the compensatory mechanisms fail, even small amounts of additional blood can cause the intracranial pressure to rise rapidly, and the client’s neurological status deteriorates quickly.
- B. After spinal cord injury, the client can develop paralytic ileus, which is characterized by the absence of bowel sounds and abdominal distention. Development of a stress ulcer can be detected by hematest positive NG tube aspirate or stool. A history of diarrhea is irrelevant.
- B. The most frequent cause of autonomic dysreflexia is a distended bladder. Straight catherization should be done every 4 to 6 hours, and Foley catheters should be checked frequently to prevent kinks in the tubing. Constipation and fecal impaction are other causes, so maintaining bowel regularity is important. Other causes include stimulation of the skin from tactile, thermal, or painful stimuli. The nurse administers care to minimize risk in these areas.
- C. Reflex vasodilation below the level of the spinal cord injury places the client at risk for orthostatic hypotension, which may be profound. Measures to minimize this include measuring vital signs before and during position changes, use of a tilt-table with early mobilization, and changing the client’s position slowly. Venous pooling can be reduced by using Teds (compression stockings) or pneumatic boots. Vasopressor medications are administered per protocol.
- D. Spinal immobilization is necessary after spinal cord injury to prevent further damage and insult to the spinal cord. Whenever possible, the client is placed on a Stryker frame, which allows the nurse to turn the client to prevent complications of immobility, while maintaining alignment of the spine. If a Stryker frame is not available, a firm mattress with a bed board should be used.
- C. Resolution of spinal shock is occurring when there is a return of reflexes (especially flexors to noxious cutaneous stimuli), a state of hyperreflexia rather than flaccidity, reflex emptying of the bladder, and a positive Babinski’s reflex.
- C, A, D, B, E. Autonomic dysreflexia is characterized by severe hypertension, bradycardia, severe headache, nasal stuffiness, and flushing. The cause is a noxious stimulus, most often a distended bladder or constipation. Autonomic dysreflexia is a neurological emergency and must be treated promptly to prevent a hypertensive stroke. Immediate nursing actions are to sit the client up in bed in a high-Fowler’s position and remove the noxious stimulus. The nurse should loosen any tight clothing and then check for bladder distention. If the client has a foley catheter, the nurse should check for kinks in the tubing. The nurse also would check for a fecal impaction and disimpact if necessary. The physician is contacted especially if these actions do not relieve the signs and symptoms. Antihypertensive medications may be prescribed by the physician to minimize cerebral hypertension.
- A. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage.
- A. Neural control of respiration takes place in the brain stem. Deterioration and pressure produce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chest movements, and nasal flaring are more characteristic of respiratory distress or hypoxia.
- C. Normal ICP is 15 mm Hg or less. Hyperventilation causes vasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate, which in turn increases ICP. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg.
- D. A decrease in the client’s LOC is an early indicator of deterioration of the client’s neurological status. Changes in LOC, such as restlessness and irritability, may be subtle. Widening of the pulse pressure, decrease in the pulse rate, and dilated, fixed pupils occur later if the increased ICP is not treated.
- B. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. Using a jacket or wrist restraint or tucking the client’s arms and hands under the draw sheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.
- D. Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain, or pons and is demonstrated clinically by arching of the back, rigid extension of the extremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and adduction of arms with flexion of the elbows, wrists, and fingers described decorticate posturing, which indicates damage to corticospinal tracts and cerebral hemispheres.
- B. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is superior and posterior to the pons and medulla, clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. The physician is notified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the GCS, but time is also of the essence. Checking deep tendon reflexes is one part of the GCS analysis.
- B. Elevating the HOB to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite of the incision, if not contraindicated by the ICP; is used forsupratentorial craniotomies.
- B, C, D. A client who is brain dead typically demonstrates nonreactive dilated pupils and nonreactive or absent corneal and gag reflexes. The client may still have spinal reflexes such as deep tendon and Babinski reflexes in brain death. Decerebrate or decorticate posturing would not be seen.
- B. When used to treat status epilepticus, diazepam may be given every 10 to 15 minutes, as needed, to a maximum dose of 30 mg. The nurse can repeat the regimen in 2 to 4 hours, if necessary, but the total dose shouldn’t exceed 100 mg in 24 hours. The nurse must not administer I.V. diazepam faster than 5 mg/minute. Therefore, the dose can’t be repeated in 30 to 45 seconds because the first dose wouldn’t have been administered completely by that time. Waiting longer than 15 minutes to repeat the dose would increase the client’s risk of complications associated with status epilepticus.