Quiz 5 Flashcards
Admission vital signs for a patient who has a brain injury are blood pressure of 128/68 mm, pulse of 110beats/min and of respiration 26 breaths/min. Which set of vital signs, if taken 1 hr later will be the most of concern?
Blood pressure 154/68 mm Hg, pulse 56 beats/min, respirations 12 breaths/min
A 20 YO is admitted with a head injury after a collision while playing sports. After noting that the patient has developed clear nasal drainage, which action would the nurse take?
Check the drainage for glucose content.
Which action will the emergency department nurse anticipate for a patient diagnosed with a
concussion who did not lose consciousness?
Provide discharge instructions about monitoring the neurological status.
The nurse is admitting a patient with a basal skull fracture. The nurse notes ecchymoses around both eyes and clear drainage from the patients nose. Which admission order would the nurse question?
Insert nasogastric tube to low suction.
An athlete is seen in the clinic 6 weeks after a concussion. Which assessment information
will the nurse collect to determine whether the patient is developing post-concussion syndrome
Short-term memory
Which statement by a patient who is being discharged from the emergency department (ED) after a concussion indicates a need for intervention by the nurse?
I am going to drive home and go right to bed.
What medication to avoid with ICP
Anticoagulants
A patient had an intracranial hemorrhage and their ICP is increasing. How can you tell ICP is
increasing?
JVD
A nurse in the emergency department is monitoring a client who has a cervical spinal cord injury from a fall. The
nurse should monitor the client for which of the following complications? (Select all that apply.)
Hypotension
absent bowel sounds
diminshed gag reflex
A rehabilitation nurse is caring for a client who has had a spinal cord injury that resulted in paraplegia. After a week on the unit, the nurse notes that the client is withdrawn and increasingly resistant to rehabilitative efforts by the staff. Which of the following actions should the nurse take?
Establish a plan of care with the client that sets attainable goals.
Patient with a T4 spinal cord injury complaining of
severe pounding headache and blurred vision. Flushed
skin and diaphoresis noted upper chest and face. BP
190/100 mmHg pulse 40 beats/min. Foley draining
clear yellow urine; 60 cc/4 hours. Suspect autonomic
dysreflexia. Interventions implemented.
Based on the information in the nurse’s progress note, which interventions
should the nurse implement? Select all that apply.
Bladder distention
Raise HOB
Loosen restrictive clothing
A nurse is caring for a client who has had a spinal cord injury at the level of the T2-T3 vertebrae. When planning care, the nurse should anticipate which of the following types of disability?
Paraplegia
A nurse is developing a plan of care to prevent skin breakdown for a client with a spinal cord injury and paralysis. Which of the following nursing actions are appropriate? (Select all that apply.)
Place heels with a pillow
prevent moisture
A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic
dysreflexia. Which of the following actions should the nurse take first?
Place the client in a high-Fowler’s position.
A nurse is teaching the family of a client who is receiving treatment for a spinal cord injury with a halo fixation device. Which of the following statements should the nurse make?
“The purpose of this device is to immobilize the cervical spine.”
A nurse is caring for a client who has a spinal cord injury and suspects the client is developing autonomic
dysreflexia. Which of the following actions should the nurse take first?
Place the client in a sitting position.
A nurse is assessing a client who has a spinal cord injury. Which of the following actions should the nurse take to
monitor C4 function?
Apply downward pressure while the client shrugs his shoulders upward.
A nurse is caring for a client who is postoperative following a laminectomy with spinal fusion. Which of the following actions should the nurse take?
Monitor sensory perception of the lower extremities.
A nurse is caring for a client who has paraplegia following an automobile accident. The client is on an intermittent urinary catheterization program. Which of the following findings indicates the need for catheterization?
Dribbling of urine
A nurse is assessing a client who has a traumatic head injury to determine motor function response. Which of the following client responses to painful stimulus is expected?
Pushes the painful stimulus away
A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?
Monitor the client for an elevated temperature
A nurse is assessing a client who has Bell’s palsy. Which of the following findings should the nurse expect?
(Select all that apply.)
Muscle distortion
Pain behind the ear
Impaired taste
A nurse in the emergency department is caring for a client who sustained a head injury. The nurse notes the
client’s IV fluids are infusing at 125 mL/hr. Which of the following is an appropriate action by the nurse?
Slow the rate to 50 mL/hr.
(you want to slow the rate because it will cause an increase in ICP)
A nurse is assessing a client following a head injury and a brief loss of consciousness. Which of the following findings should the nurse report to the provider?
Small drops of clear fluid in left ear
A patient underwent a rhizotomy (removes sensation from painful nerve by killing that nerve
fiver) and now has dysphagia. What should the nurse do?
- puree the food or chop it up into small bites
A nurse is reinforcing discharge instructions with a client following a laminectomy. Which of the following instructions should the nurse include?
“Sit in straight-back chairs.”
After the emergency department nurse has received a status report on the following patients
with head injuries, which patient would the nurse assess first?
A 50-yr-old patient whose right pupil is 10 mm and unresponsive to light
A nurse admits a client who has a subarachnoid hemorrhage and increased intracranial pressure (ICP). Which of the following medications should the nurse expect to administer to decrease ICP?
mannitol
A patient has an incomplete left spinal cord lesion at the level of T7, resulting in
Brown-Séquard syndrome. Which action would the nurse include in the plan of care?
Positioning the patient‘s left leg when turning the patient
A nurse is caring for a client who was involved in a motor vehicle accident. The client is alert and oriented and reports a loss of consciousness immediately after the accident. Which of the following additional manifestations
should the nurse assess the client for?
pupillary dilation
persistent headaches
difficulty waking
A nurse is reinforcing teaching with a newly licensed nurse about coup and contrecoup injuries. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?
The coup injury is the primary focal injury, and the contrecoup injury occurs on the opposite side of the
brain
A nurse is caring for a client who has a traumatic brain injury (TBI). Which of the following should the nurse understand is a possible consequence of a TBI?
Disruption of cellular function and blood vessel damage
