TBIs
A patient is admitted to the emergency room with a fractured skull sustained in a motorcycle accident. The nurse notes fluid leaking from the patient's ears. The nurse knows this is a probable sign of which type of skull fracture?
A. Simple
B. Comminuted
C. Depressed
D. Basilar
D. Basilar
Basilar skull fractures are suspected when cerebrospinal fluid (CSF) escapes from the ears (CSF otorrhea) and/or the nose (CSF rhinorrhea).
An older adult patient has been brought to the emergency department (ED) after being found unconscious by a neighbor. What action should be the ED nurse's highest priority in the care of this patient?
A. Obtain a full set of vital signs.
B. Assess the patient's level of consciousness (LOC).
C. Maintain the patency of the patient's airway.
E. Establish IV access.
C. Maintain the patency of the patient's airway.
The first priority of treatment for the patient with altered LOC is to obtain and maintain a patent airway. IV access and thorough assessment are necessary but are superseded by the importance of obtaining and maintaining a patent airway.
A nurse is caring for a patient who has been diagnosed with expressive aphasia after a stroke. Which of the following statements best describes this condition?
A) The patient can understand language but struggles to express thoughts verbally.
B) The patient has difficulty understanding spoken or written language.
C) The patient cannot recognize objects or faces.
D) The patient has trouble coordinating movements required for speech.
A) The patient can understand language but struggles to express thoughts verbally.
Rationale: Expressive aphasia, often associated with Broca's area damage, affects the ability to produce speech while comprehension remains relatively intact.
A family member brings the patient to the clinic for a follow-up visit after a stroke. The family member asks the nurse what he can do to decrease his chance of having another stroke. What would be the nurse's best answer?
A. “Have your heart checked.”
B. “Stop smoking.”
C. “Get medication to bring down your sodium levels.”
D. “Eat a nutritious diet.”
B.
A nurse is caring for a patient in the intensive care unit when a family member suddenly lashes out in anger, blaming the nurse for their loved one's condition. Which of the following responses by the nurse demonstrates effective therapeutic communication?
A) "I understand you're upset, but I’m just doing my job."
B) "I’m sorry you feel that way; can you tell me more about your concerns?"
C) "You need to calm down; yelling won’t help your loved one."
D) "Let me get the doctor to talk to you instead."
Correct Answer: B) "I’m sorry you feel that way; can you tell me more about your concerns?"
Rationale: This response acknowledges the family member's feelings and invites them to express their concerns, fostering a supportive dialogue and helping to de-escalate the situation.
A nurse is reviewing a CT scan of the brain, which states that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
A. Symptoms will evolve over a period of 1 week.
B. Monitoring is needed as rapid neurologic deterioration may occur.
C. The crash cart with defibrillator is kept nearby.
D. Bleeding continues into the intracerebral area.
B. Monitoring is needed as rapid neurologic deterioration may occur
The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
The school nurse has been called to the football field, where a player is laying immobile on the field after landing awkwardly on the head during a play. While awaiting an ambulance, what action should the nurse perform?
A. Ensure that the player is not moved.
B. Obtain the player's vital signs, if possible.
C. Perform a rapid assessment of the player's range of motion.
D. Assess the player's reflexes.
A. Ensure that the player is not moved.
At the scene of the injury, the client must be immobilized on a spinal (back) board, with the head and neck maintained in a neutral position, to prevent an incomplete injury from becoming complete. This is a priority over determining the client's vital signs. It would be inappropriate to test ROM or reflexes.
A nurse is assessing a patient who has been diagnosed with apraxia following a stroke. Which of the following findings would the nurse expect?
A) The patient cannot recognize familiar faces.
B) The patient has difficulty performing purposeful movements despite having the physical ability to do so.
C) The patient struggles to form words but can communicate non-verbally.
D) The patient is unable to understand written or spoken language.
B) The patient has difficulty performing purposeful movements despite having the physical ability to do so.
Rationale: Apraxia affects the ability to plan and execute movements needed for tasks, despite intact motor function.
The client has been diagnosed with aphasia after suffering a stroke. What can the nurse do to best make the client's atmosphere more conducive to communication?
A. Provide a board of commonly used needs and phrases.
B. Have the client speak to loved ones on the phone daily.
C. Help the client complete their sentences as needed.
D. Speak in a loud and deliberate voice to the client.
A. The inability to talk on the telephone or answer a question or exclusion from conversation causes anger, frustration, fear of the future, and hopelessness. A common pitfall is for the nurse or other health care team member to complete the thoughts or sentences of the client. This should be avoided because it may cause the client to feel more frustrated at not being allowed to speak and may deter efforts to practice putting thoughts together and completing a sentence. The client may also benefit from a communication board, which has pictures of commonly requested needs and phrases. The board may be translated into several languages.
A halo sign is indicative of which of the following complication of brain injury?
A. Cerebrospinal fluid (CSF) leak
B. Seizure
C. Cerebral edema
D. Ischemia
A. Cerebrospinal fluid (CSF) leak
A halo sign (a blood stain surrounded by a yellowish stain) may be seen on bed linens or on the head dressing and is highly suggestive of a CSF leak. A positive halo sign is not indicative of seizure, cerebral ischemia, or cerebral edema.
A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of:
A. Decreased intravascular volume
B. Increased intracranial pressure (ICP)
C. Ischemic cerebrovascular accident (CVA)
D. Brain tissue necrosis
B. Increased intracranial pressure (ICP)
The pathological effects of an epidural hematoma are primarily a result of the consequent increase in ICP. Blood loss, ischemia, and necrosis are not the primary sequelae of an epidural hematoma.
The nurse is caring for a female client who is newly paraplegic. The client and the client’s spouse ask the nurse about their reproductive options. Which suggestion by the nurse is most helpful?
A. Adoption is an option to complete your family but not put your life in jeopardy.
B. Conception is not impaired; the birth process is determined with the physician.
C. Birth via surrogate is best because your baby can be implanted in another woman.
D. Sterilization is best; it would be difficult to care for a baby in your condition.
B. Conception is not impaired; the birth process is determined with the physician.
The nurse’s role is to provide facts without inserting personal opinions. The fact is that the woman can conceive and bear children. Suggesting adoption, a surrogate, or sterilization is not appropriate. Providing information is appropriate.
A patient who had a stroke exhibits agnosia. Which of the following statements best describes this condition?
A) The patient cannot perform tasks despite having the ability to do so.
B) The patient has difficulty recognizing familiar objects or faces.
C) The patient struggles to articulate words but understands them.
D) The patient experiences loss of motor function on one side of the body.
Correct Answer: B) The patient has difficulty recognizing familiar objects or faces.
Rationale: Agnosia is the inability to recognize objects, people, or sounds despite having intact sensory function, often resulting from brain damage.
A nurse is assessing a patient who presents with sudden onset of weakness on one side of the body and difficulty speaking. The physician suspects a stroke and considers administering tissue Plasminogen Activator (tPA). Which type of stroke is tPA indicated for?
A) Hemorrhagic stroke
B) Transient ischemic attack (TIA)
C) Acute ischemic stroke
D) Subarachnoid hemorrhage
Correct Answer: C) Acute ischemic stroke
Rationale: tPA is specifically indicated for acute ischemic strokes, where blood flow to the brain is obstructed by a clot. It is not used for hemorrhagic strokes or TIAs.
Osmotic diuretics are an essential intervention for reducing cerebral edema. Which of the following drugs is most frequently prescribed for this situation?
A. Mannitol
B. Glucose
C. Glycerin
D. Hypertonic saline
A. Mannitol is considered the “gold standard” for reducing increased ICP.
While snowboarding, a client fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?
A. concussion
B. laceration
C. contusion
D. skull fracture
A. concussion
A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.
A client is admitted to the neurologic ICU with a spinal cord injury. When assessing the client the nurse notes there is a sudden loss of sympathetic reflex activity in the spinal cord below the level of injury. What should the nurse suspect?
A. Epidural hemorrhage
B. Hypertensive emergency
C. Spinal shock
D. Autonomic Dysreflexia
C. Spinal shock
In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur.
A nurse is caring for a client who has a spinal cord injury at the fourth cervical level. Which of the following mobility options should the nurse anticipate for this client?
A. Ultra-light wheelchairs
B. Hand controlled wheelchair
C. Manual wheelchair
D. Sip-and-puff device operated wheelchair
D. Sip-and-puff device operated wheelchair
A nurse is teaching a community class that those experiencing symptoms of ischemic stroke need to enter the medical system early. The primary reason for this is which of the following?
A. Thrombolytic therapy has a time window of only 3 hours.
B. A ruptured intracranial aneurysm must quickly be repaired.
C. Intracranial pressure is increased by a space-occupying bleed.
D. A ruptured arteriovenous malformation will cause deficits until it is stopped.
A. Currently approved thrombolytic therapy for ischemic strokes has a treatment window of only 3 hours after the onset of symptoms. Urgency is needed on the part of the public for rapid entry into the medical system. The other three choices are related to hemorrhagic strokes.
A nurse is meeting with the family of a patient who has sustained a spinal cord injury (SCI). The family expresses feelings of confusion and fear about the patient's prognosis and care needs. Which of the following responses by the nurse best demonstrates effective therapeutic communication?
A) "I understand your concerns, but you should try to stay positive."
B) "What specific questions do you have about your loved one’s condition?"
C) "Everything will be fine; the doctors know what they are doing."
D) "It's common for families to feel this way, but there's no need to worry."
Correct Answer: B) "What specific questions do you have about your loved one’s condition?"
Rationale: This response encourages open dialogue, invites the family to express their concerns, and addresses their specific needs for information, demonstrating effective therapeutic communication.
A nurse is caring for a client who had a severe traumatic brain injury 3 weeks ago, remains unconscious, and is unlikely to recover. While bathing the client, the assistive personnel (AP) talks to him about current events. The client's partner asks the nurse why the AP talks to the client. Which of the following responses should the nurse make?
A. "I'm really not sure why the assistant is talking to him. Perhaps you should ask her."
B. "Although your partner is not responding to us, he might still be able to hear."
C. “Don’t let that concern you. She talks to all her clients, no matter what.”
D. "She is an excellent caregiver. She has many others to care for, but she takes the time to talk to your partner."
B. "Although your partner is not responding to us, he might still be able to hear."
Hearing is one of the last senses to fade in clients who are unconscious. The nurse should encourage the partner and the staff to talk to him about neutral topics like the weather and benign current events to provide minimally stressful sensory stimulation.
A nurse is monitoring a patient with a spinal cord injury for signs of autonomic dysreflexia. Which of the following symptoms should the nurse be aware of? (Select all that apply.)
A) Severe headache
B) Sweating
C) Bradycardia
D) Flushing of the skin
E) Hypotension
Correct Answers: A), B), C), D)
Rationale: Autonomic dysreflexia is characterized by severe headache, sweating above the level of the injury, bradycardia, flushing of the skin above the injury site, and piloerection. Hypotension is not typically a sign of autonomic dysreflexia; instead, hypertension is more common.
A nurse is caring for a client who has a spinal cord injury at T-4. The nurse should recognize that the client is at risk for autonomic dysreflexia. Which of the following interventions should the nurse take to prevent autonomic dysreflexia?
A. Monitor for elevated blood pressure.
B. Provide analgesia for headaches.
C. Prevent bladder distention.
D. Elevate the client's head.
C. Prevent bladder distention.
The nurse practitioner is able to correlate a client's neurologic deficits with the location in the brain affected by ischemia or hemorrhage. For a client with a left hemispheric stroke, the nurse would expect to see:
A. Disorientation
B. Left visual field deficit.
C. Right-sided paralysis.
D. Impulsive behavior.
C. A left hemispheric stroke will cause right-sided weakness or paralysis. Because upper motor neurons decussate, a disturbance on one side of the body can cause damage on the opposite side of the brain. Refer to Box 47-2 in the text.
A nurse is reinforcing teaching to a client who has a spinal cord injury about sexual stimulation. Which of the following statements by the nurse should be included in the teaching?
A. "You must experiment with your body to find out what stimulation is enjoyable after your injury."
B. "Clients who have a spinal cord injury are not aroused by touch around the groin area."
C. "You will not be able to have an intimate relationship with anyone after a spinal cord injury."
D. "You should not feel undesirable after your injury. You are still nice-looking."
A. "You must experiment with your body to find out what stimulation is enjoyable after your injury."
It is important for clients to identify what type of stimulation can cause sexual excitement following their injury.