Week 7 Quiz Flashcards
A patient with a head injury has admission vital signs of blood pressure 128/68, pulse 110, and respirations 26. Which of these vital signs, if taken 1 hour after admission, will be of most concern to the nurse?
a. Blood pressure 156/60, pulse 55, respirations 12
b. Blood pressure 130/72, pulse 90, respirations 32
c. Blood pressure 148/78, pulse 112, respirations 28
d. Blood pressure 110/70, pulse 120, respirations 30
ANS: A
Systolic hypertension with widening pulse pressure, bradycardia, and respiratory changes represent Cushing’s triad and indicate that the intracranial pressure (ICP) has increased, and brain herniation may be imminent unless immediate action is taken to reduce ICP. The other vital signs may indicate the need for changes in treatment, but they are not indicative of an immediately life-threatening process.
If you have a patient with a brain injury what vital signs would you be concerned about?
Bradycardia
Systolic blood pressure is high.
Choose the highest blood pressure***
What is cushings triad?
widened pulse pressure
decreased respirations
decreased heart rate
A 20-yr-old male patient is admitted with a head injury after a collision while playing football. After noting that the patient has developed clear nasal drainage, which action should the nurse take?
a. Have the patient gently blow the nose.
b. Check the drainage for glucose content.
c. Teach the patient that rhinorrhea is expected after a head injury.
d. Obtain a specimen of the fluid to send for culture and sensitivity.
Answer: b. Check the drainage for glucose content.
Rationale: Clear nasal drainage in a patient with a head injury suggests a dural tear and cerebrospinal fluid (CSF) leakage. If the drainage is CSF, it will test positive for glucose. Fluid leaking from the nose will have normal nasal flora, so culture and sensitivity will not be useful. Blowing the nose is avoided to prevent CSF leakage.
A person with a concussion what are we going to do?
Keep patient awake; give instructions on neuro status (alert, respiratory, and pupils)
A person that has a skull fracture down by the basal and note they have racoon eyes with clear drainage from their nose. What order are we going to question from the provider?
Question the order for NG Tube to low suction (it can cause meningitis)
A person with a concussion and have post term concussion what are we going to see? Post concussion syndrome:
short term memory loss persistent headache lethargy
personality
behavior changes
A person with a concussion getting discharged in the ER what statement would require further instruction?
b. Do not go to sleep early
The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant other?
- Awaken the client every two (2) hours.
- Monitor for increased intracranial pressure.
- Observe frequently for hypervigilance.
- Offer the client food every three (3) to four (4) hours.
- Awakening the client every two (2) hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety—all signs of postconcussion syndrome—that would warrant the significant other’s taking the client back to the emergency department.
A patient with a brain injury what do we need to report to the provider?
Report anticoagulants (it can increase intracranial hemorrhage)
A person has intracranial hemorrhage and have ICP what can we look at the neck for that indicates an increase in ICP
Jugular vein distention: indicates increased ICP
What is the tx plan for increased ICP?
mannitol
reduce stimuli
increase HOB
normal ICP range?
5-15 mm Hg
what is a bad ICP level?
hennythanggg ovaaa 20
SATA
Poor gag reflex (dysphagia)
Absent bowel sounds
Low blood pressure (hypotension)
Do NOT select polyuria and hyperthermia
A patient with a spinal cord injury has paraplegia. What are we going to do?
Establish a plan of care to set attainable goals
A person with dysreflexia because T4 paralysis from chest down what are they going to have?
A. Hyperreflexia
B. Bladder distended (catheter placed)
C> Elevated BP and headache, flushed face
B. Bladder distended (catheter placed)
If a person has a injury at level of T2-T3 what is it going to cause?
A. Paraplegia: paralysis of both legs (injury at or below T1)
B. Hemiplegia: paralysis on one side (CVA or Stroke)
C. Quadriplegia: above C7
A. Paraplegia: paralysis of both legs (injury at or below T1)
SATA 2 answers: skin breakdown for patient with spinal cord injury and paralysis: cervical spinal cord injury from a fall
a. Raise heels with pillow
b. Prevent moisture
A person with autonomic dysreflexia with a high BP after having a spinal cord injury what position are we going to place them in to reduce BP and ICP ?
Semi or High Fowler to reduce BP and ICP
Halo fixation device: what is it trying to immobilize what part of the spine?
Cervical Spine: it is on for 8-12 weeks
immobilization of the upper spine
Spinal cord injury about autonomic dysreflexia. What will we do to prevent persons BP high and ICP high? What will we do to decrease them?
Reposition the patient between Semi and High Fowler
A person with a spinal cord injury What are we going to assess for in the C4 & C5 function what are we going to do?
Have patient shrug their shoulders and push down (cranial nerve 11)
A person who has a spinal cord injury and assisting the client with bathing what are we going to give them to promote independence?
Give the patient a long handle sponge to assist with bathing, bathwater no more than 115 degrees, wall mounted soap dispenser, hand held shower head
A laminectomy down to the lumbar what part of the body has been affected to the legs what are we going to do?
Make sure patient has sensory perception of lower extremities, check motor skills of legs (raise legs)
A person with paraplegia from a Motor Vehicle Accident what indicated the need for catheterization?
Need for catheterization if patient has dribbling or incontinence of urine
A person with traumatic head injury which will indicate the motor function response?
Response to pain and push hand away
A patient with a halo fixation device what are we going to report?
Report elevated temperature (infection from screws in skull, purulent drainage)
Bell’s palsy SATA (3 answers) CN 7
Impaired taste (difficulty with speech)
Pain behind the ear *tinnitus nor hearing loss) Muscle distortion (Facial paralysis)
A person who has sustained a head injury and is receiving IV fluids, what are we going to do the IV fluids if its above 100ml/hr?
Decrease infusion rate from 100 ml/hr to 50 ml/hr (to decrease cerebral edema and ICP)
call provider
A person with a head injury and brief loss of consciousness and they have clear fluid coming out of the ear what does that mean?
The fluid can be CSF and can indicate skull fracture
A person has dysphagia and rhizotomy, how would you encourage the patient to eat their food?
Dysphagia: cut food into small bites
A person who had a laminectomy how are we going to support their spine?
Support spine by sitting in straight back chair
If a patient has their pupils that is at a 10mm what does that mean? Which patient are you going to assess first?
Unresponsive to light from intracranial hemorrhage or ICP
What diuretic is a person with ICP and has a low GCS and cerebral hemorrhage going to get?
Mannitol (osmotic diuretic)
A person who has an injury above the T7 and has brown sequard syndrome what are we going to do? a. Neurologic syndrome from spinal cord above T7
b. Paralysis, ipsilateral, loss of pain and sensation
c. ***Reposition patient based on paralysis of affected leg (left or right leg)
c. ***Reposition patient based on paralysis of affected leg (left or right leg)
SATA
question with a patient in a motor vehicle accident
Pupils dilated
Persistent headaches
Difficulty walking
Teaching a patient about coup and contrecoup injury what indicates an understanding of the teaching
Coup: primary focal injury
Contrecoup: injury on opposite side of brain
A person who had a traumatic brain injury what are we going to teach them about a TBI
Disruption of cellular function and may have blood vessel damage.
If someone has a concussion what will happen to their LOC?
brief disruption no longer than 5 minutes and they may experience retrograde amnesia
what are some signs someone is experiencing post-concussion syndrome?
- Persistent HA, lethargy
- Shortened attention span
- decreased short term memory
- changes in intellectual ability
- personality, behavior changes
What are some signs someone is experiencing a DAI? (diffuse axonal injury)
- Global cerebral edema
- Increased ICP, coma
- Posturing
What are some nursing actions for a head injury?
- Elevate HOB
- apply loose collection pad under nose or over ear
- Direct client not to sneeze or blow nose
- Do not perform nasotracheal suctioning
- Do not insert NG tube
what does the level of injury for C1-C4 mean?
the pt will be ventilator dependent
what does the level of injury for C1-C8 mean?
limited proprioception
what does the level of injury for T1-T8 mean?
trunk movement affected, lack of abdominal control
what does the level of injury for T9 - T12 mean?
limited abdominal control
what does the level of injury for L1-S5 mean?
loss of bowel and bladder function, sexual function affected
The higher the level of injury means what?
the higher the level on injury, the more permanent damage they will have
If they have T6 level of injury or higher what does this mean?
they will likely experience autonomic dysreflexia
if someone has a complete lesion, what may they experience?
total loss of motor, sensory, and reflex activity
Someone with anterior cord syndrome may experience what?
problems with pain, temp, position, vibration, touch sense, and motor capabilities in general
if someone has brown-squared syndrome and the area of damage is the L spinal cord injury what may they experience?
R sided loss of pain, temp, and light touch (opposite of damage)
BUT they will have loss of motor function vibration, position, and deep touch sensation on the SAME side as the injury
Central cord syndrome…what does the pt experience?
loss of motor function
What is specific to Conus medullar is and cause equine syndrome?
neurogenic bowel and bladder
A nurse is caring for a client who has paraplegia and is on an intermittent urinary catheterization program.
Which of the following findings indicates to the nurse the need to catheterize the client?
A. Reflex incontinence
B. Urge incontinence
C. Nocturnal enuresis
D. Suprapubic discomfort
D. Suprapubic discomfort
Suprapubic discomfort or pain in the area above the pubic bone could be a sign of bladder distension, which is a common complication in individuals with spinal cord injuries. Bladder distension can occur when the bladder becomes overly full and can’t empty, causing discomfort or pain in the lower abdomen. This is a clear indication for the need to catheterize the client.
The nurse is caring for a client with Bell palsy. Which of the following assessment findings does the nurse expect? SATA
1. Change in lacrimation on the affected area
2. Electric shock (like pain in the lips and gums)
3. Flattening of the nasolabial fold
4. Inability to smile symmetrically
5. Severe pain along the cheekbone
- Change in lacrimation on the affected area
- Flattening of the nasolabial fold
- Inability to smile symmetrically
Which data collection finding supports the possible diagnosis of Bell’s palsy?
Speech or chewing difficulties accompanied by facial droop
The nurse is planning care for a client with Bell’s palsy. Which measure should be included in the plan?
Instill artificial tears and wear a patch over the affected eye at night.
A client presents with a head injury after being in a motor vehicle accident and is diagnosed with a brain contusion with a coup-contrecoup injury. The client is stabilized and sent home, but the healthcare provider instructs the client to return in 3 days for a repeat MRI. Which explains the rationale for a repeat MRI?
A. It is protocol for all MRIs to be repeated in traumatic brain injuries (TBIs).
B. The MRI will be repeated to determine the cause of the client’s injuries.
C. It can take hours to days for contusions to form from a coup-contrecoup injury.
D. The MRI can determine the grade of concussion that the client sustained.
C. It can take hours to days for contusions to form from a coup-contrecoup injury.
Pt with concussion experiences short term memory, this could indicate?
post concussion syndrome
Pt is discharged from the ER, what are some teachings?
do not drive home from the ER
monitor for neuro changes if there happen come back
Complications of a spinal cord injury?
difficult swallowing (poor gag reflex), absent bowel sounds (paralytic illness), hypotension
Pt is paraplegic and in rehab, what should the nurse ensure to do?
establish plan of care
Pt with T4 spinal cord injury what should the nurse plan on doing?
catheterize pt
What is the purpose of the Halo fixation device?
immobilize C-spine
How to assess C4 C5 function?
have pt shrug shoulders
What indicates need for catheterization?
dribble of urine
Pt had a laminectomy w/ spinal fusion on lumbar spine, how do we check sensory perception in limbs?
pt raise legs and tickle bottom of feet
What should be assessed on a pt with a halo fixation device?
temperature
What could indicate a skull fracture?
otorrhea ( CSF from ear)
pt with left spinal cord injury due to T7 result in brown sequard syndrome…what do you do?
turn pt on the side and reposition leg underneath
Define coup
primary focal injury
Define contrecoup?
injury that occurs on the opposite side of the Brain
Nurse would provide teaching to pt with traumatic brain injury…?
it was a disruption of cellular function and you may have blood vessel damage
Pt loses consciousness after car crash…
pupils dilated
persistent HA
Difficulty swallowing
Pt has T4 spinal cord injury. What indicates risk for autonomic dysreflexia?
bladder distended
spinal cord injury T2-T3 which disability?
paraplegia go both legs
Pt with traumatic brain injury. Which actions to include in plan of care?
pushing away from pain
pt with bells palsy, what do you expect to find?
muscle distortion, impaired taste, pain behind ear
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?
(Select All that Apply.)
A. Pupillary dilation
B. Persistent headache
C. Presence of hand tremors
D. Difficulty waking
E. Foot drop
A. Pupillary dilation
B. Persistent headache
D. Difficulty waking
