Neurologic Trauma - PREP U

Question 1

Which of the following is the earliest and most significant sign of increasing intracranial pressure (ICP)?

Answer 1

change in LOC (level of consciousness)

Question 2

what is it called when blood collects between the dura mater and the arachnoid membrane?

** this space normally contains a thin layer/ cushion of fluid**

Answer 2

Subdural hematoma

Question 3

An epidural hematoma is bleeding between the inner skull and the dura, compressing the brain underneath. An epidural hematoma is AKA _______ ________.

Answer 3

extradural hematoma

Question 4

A patient coming into the ER is reported to have a “Battle Sign,” what is this referring to?

Answer 4

bruising behind the ear, specifically to the mastoid process

Question 5

A client sustained a head trauma and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as?

Answer 5

intracerebral hematoma

Question 6

The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?

Answer 6

cerebral spinal fluid (CSF) leaking from the ear

Question 7

-periorbital ecchymosis (raccoon’s eyes)
-post-mastoid ecchymosis (Battle sign)
-otorrhea
-rhinorrhea
-loss of cranial nerve I (olfactory nerve) function

After assessing these findings what trauma would be suspected?

Answer 7

basilar skull fracture - is a break in one or more bones at the base of the skull

Question 8

When caring for a client who is post–intracranial surgery what is the most important parameter to monitor?

Answer 8

body temperature

Question 9

What are the clinical manifestations of CUSHINGS TRIAD?

Answer 9

-hypertension
-bradycardia
-bradypnea

Question 10

Signs of INCREASING ICP are called the CUSHING REFLEX. what 3 signs does this consist of?

Answer 10

-increase on systolic BP
-widened pulse pressure
-bradycardia

Question 11

In a spinal cord injury, neurogenic shock develops due to loss of the autonomic nervous system functioning below the level of the lesion. Which of the following indicators of neurogenic shock would the nurse expect to find?

Answer 11

-hypotension
-venous pooling
-tachypnea
-hypothermia
-decreased cardiac output

Question 12

what are the 3 cardinal signs of brain death?

Answer 12

-apnea
-absence of brainstem reflexes
-coma

Question 13

Autonomic dysreflexia is an acute emergency that occurs with spinal cord injury as a result of exaggerated autonomic responses to stimuli. (IE. full bladder, constipation, tight clothing, ingrown toenail) - What manifestations occur?

Answer 13

-increased BP
-bradycardia
-bad headache
-skin above injured area turns red/ blotchy
-diaphoresis
-anxious
-stuffy nose
-blurred vision

Question 14

if a patient is experiencing autonomic dysreflexia due to a SCI, what should you do right away?

Answer 14

• sit the patient up/ raise their upper body to bring their BP down

IE.
-if bladder is full - empty
-if constipated - stool softener
-clothes too tight - loosen clothes