Chapter 63- Management of Patients With Neurologic Trauma
Chapter 63: Management of Patients With Neurologic Trauma
Multiple Choice
1. After sustaining
... [Show More] a fall at home, a patient is brought to the emergency room exhibiting altered
level of consciousness. Following a skull x-ray, the patient is diagnosed with a basilar skull
fracture. Which sign should alert the nurse to this type of fracture?
A) Babinski's sign
B) Kernig's sign
C) Battle's sign
D) Brudzinski's sign
Ans: C
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: A-1
Feedback: An area of ecchymosis (bruising) may be seen over the mastoid (Battle's sign) in a
basilar skull fracture. A positive Kernig's sign and positive Brudzinski's sign indicate meningeal
irritation. Babinski's sign (reflex) is indicative of central nervous system (CNS) disease in the
corticospinal tract.
2. A patient brought to the trauma center by ambulance sustained a high cervical spinal cord
injury 2 hours ago. The nurse knows that which of the following medications will be given to
prevent further spinal cord damage?
A) Furosemide (Lasix)
B) Methylprednisolone (Solu-Medrol)
C) Cyclobenzaprine (Flexeril)
D) Hydralazine hydrochloride (Apresoline)
Ans: B
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: D-2
Feedback: The administration of high-dose corticosteroids, specifically methylprednisolone, has
been found to improve motor and sensory outcomes at 6 weeks, 6 months, and 1 year if given
within 8 hours of injury. Lasix, Flexeril, and Apresoline are used in the management of spinal
cord injury but do not specifically prevent further spinal cord damage.
3. A nurse is performing pin site care to a patient in halo traction following a spinal cord injury.
One of the traction pins becomes detached when the patient is turned. The nurse would be correct
in implementing which of the following priority nursing actions?
A) Complete the pin site care to decrease risk of infection.
B) Notify the neurosurgeon of the occurrence.
C) Stabilize the head in a lateral position.
D) Reattach the pin to prevent further head trauma.
Ans: B
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 7
Patient Needs: D-3
Feedback: If one of the pins becomes detached, the patient's head should be stabilized in neutral
position by one person while another notifies the neurosurgeon. A torque screwdriver is used
when the screws on the frame need tightening. Reattaching the pin would not be done as a
nursing intervention due to risk of increased injury. Pin site care would not be a priority in this
instance. Prevention of neurological injury is the priority.
4. The nurse observing a patient with autonomic dysreflexia would expect which of the
following clinical manifestations?
A) Tachycardia and hypotension
B) Bradycardia and hypertension
C) Tachycardia and hypertension
D) Bradycardia and hypotension
Ans: B
Chapter: 63
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 6
Patient Needs: A-1
Feedback: Autonomic dysreflexia is characterized by a pounding headache, profuse sweating,
nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord
lesions above T6 after spinal shock has resolved.
5. The nurse is caring for a patient with increased intracranial pressure (ICP) caused by a
traumatic brain injury. Which of the following clinical manifestations would indicate that the
patient is experiencing increased brain compression causing brain stem damage?
A) Hyperthermia
B) Tachycardia
C) Hypertension
D) Bradypnea
Ans: A
Chapter: 63
Cognitive Level: Analysis
Difficulty: Difficult
Integrated Process: Nursing Process
Objective: 3
Patient Needs: A-1
Feedback: A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases
the metabolic demands of the brain and may indicate brain stem damage. Other signs of
increasing ICP include slowing of the heart rate (bradycardia), increasing systolic blood pressure,
and widening pulse pressure. As brain compression increases, respirations become rapid, blood
pressure may decrease, and the pulse slows further.
6. Based on the nurse's knowledge of the progression of an epidural hematoma, which priority
intervention is prepared for?
A) Insertion of an intracranial (IC) monitoring device
B) Treatment with antihypertensives
C) Emergency craniotomy
D) Administration of anticoagulant therapy
Ans: C
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-1
Feedback: An epidural hematoma is considered an extreme emergency. Marked neurologic
deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening
through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Insertion
of an IC monitoring device may be done during the surgery, but is not priority for this patient.
Antihypertensive medications would not be a priority. Anticoagulant therapy should not be
ordered for a patient who has a cranial bleed because it could increase bleeding further.
7. Which of the following nursing interventions would be utilized in controlling intracranial
pressure in a severely brain-injured patient?
A) Keep the head of the bed flat
B) Maintain fluid balance with D5W solution
C) Maintain cerebral perfusion pressure at 60 mm Hg or greater
D) Initiate measures to prevent the Valsalva maneuver
Ans: D
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 2
Patient Needs: A-1
Feedback: Measures to avoid the Valsalva maneuver should be implemented in a patient with
increased intracranial pressure because it can elevate intracranial pressure and cause serious
injury. The head of the bed should be elevated 30 degrees. Fluid balance should be maintained
with normal saline solution; D5W promotes cerebral edema. Cerebral perfusion pressure (CPP)
should be maintained at greater than 70 mm Hg. See Chart 63-5.
8. The nurse discussing organ donation with a family member of a severely brain-injured patient
is asked about the signs of brain death. The nurse knows that which of the following diagnostic
tests will be done to confirm brain death?
A) Cerebral blood flow studies
B) Lumbar puncture
C) Electromyography
D) Spiral CT scan
Ans: A
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 1
Patient Needs: C
Feedback: The three cardinal signs of brain death upon clinical examination are coma, the
absence of brain stem reflexes, and apnea. Adjunctive tests such as EEG and cerebral blood flow
studies are often used to confirm brain death. A lumbar puncture, electromyography, and spiral
CT scan are used in diagnosing certain neurological diseases.
9. In planning care for a patient with a C4 spinal cord injury admitted to the intensive care unit,
the nurse would document which of the following nursing diagnoses as a priority for this patient?
A) Risk for impaired skin integrity related to immobility and sensory loss
B) Impaired physical mobility related to loss of motor function
C) Ineffective breathing patterns related to weakness of the intercostal muscles
D) Urinary retention related to inability to void spontaneously
Ans: C
Chapter: 63
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Communication/Documentation
Objective: 7
Patient Needs: A-1
Feedback: A nursing diagnosis related to breathing pattern would be the priority for this patient.
A C4 spinal cord injury requires ventilatory support because the diaphragm and intercostals are
affected. [Show Less]