Spinal Injuries
A patient is in critical care recovering from a spinal cord injury. As part of shift report, the nurse is told that the patient's injury is between C1 and C4 and involves the entire cord. The patient is on a mechanical ventilator. What is the best nursing action to provide for patient safety?
A) Be sure all side rails are up at all times.
B) Keep the bed in low position when unattended.
C) Verify that a functioning bag-mask resuscitator is at the bedside.
D) Place the call light in the patient's hand.
C) Verify that a functioning bag-mask resuscitator is at the bedside.
A patient has recently had a hemorrhagic stroke. The nurse should most strongly suspect which precipitating factor in this patient?
A) Myocardial infarction
B) Hypertension
C) Atrial infarction
D) Diabetes
B) Hypertension
A nurse is monitoring a patient recently admitted to the critical care unit with an acute brain injury. She is aware that intracranial hypertension is a major risk associated with brain injury. Which of the following findings would definitively indicate that the patient has intracranial hypertension?
A) Cerebral perfusion pressure (CPP) of 75 mm Hg
B) Intracranial pressure (ICP) of 25 mm Hg
C) Mean arterial pressure (MAP) of 150 mm Hg
D) Systolic pressure of 110 mm Hg
B) Intracranial pressure (ICP) of 25 mm Hg
The patient has an acute subdural hematoma from an acute head injury. What is the most typical symptom that the nurse would expect during the first 2 days after the injury?
A) Decreasing level of consciousness
B) Labile blood pressure
C) Cardiac dysrhythmias
D) Impingement of cranial nerve 8
A) Decreasing level of consciousness
The patient has been in a motor vehicle crash and is in the critical care unit with severe brain injury. She is comatose but when painful stimuli are applied she extends, adducts, and hyperpronates her upper extremities and has plantarflexion of the feet. This action is called what?
A) Decorticate posturing
B) Decerebrate posturing
C) Clonic-tonic activity
D) Flacidity
B) Decerebrate posturing
A patient is admitted to the emergency department after a near-drowning accident. The patient dove head-first into shallow water and has a high blood-alcohol level. Cardiopulmonary resuscitation was used at the scene. The patient is awake and alert. Considering the mechanism of injury, what is the highest nursing priority?
A) Check vital signs often.
B) Obtain an order for radiography studies.
C) Monitor pulse oximetry closely.
D) Provide cervical spine stability.
D) Provide cervical spine stability.
A patient with head trauma requires intracranial pressure (ICP) monitoring. The physician insists that the most accurate monitoring device feasible should be used for this patient. This patient also requires frequent draining of cerebrospinal fluid (CSF) while being monitored. The nurse recognizes that which ICP monitoring device would be best for this patient?
A) Intraventricular
B) Subarachnoid
C) Subdural
D) Epidural
A) Intraventricular
Patients with spinal cord injury may experience both spinal shock and neurogenic shock, and differentiating between the two is essential. What symptoms are unique to neurogenic shock?
A) Loss of motor and sensory function
B) Flaccid paralysis below the lesion
C) Presence of poikilothermia
D) Hypotension and bradycardia
D) Hypotension and bradycardia
A patient has been found to have expressive, or nonfluent, dysphasia following a stroke and is having difficulty communicating with his family. What would be the appropriate nursing intervention for this patient?
A) Explain to the family that the patient is intellectually impaired.
B) Explain to the family that the patient is unable to understand the meaning of spoken language.
C) Refer the patient to a rehabilitation specialist.
D) Give the patient a note pad so that he can write responses to questions posed to him.
D) Give the patient a note pad so that he can write responses to questions posed to him.
The patient has undergone intracerebral surgery. Knowing that interruption of the skull interferes with the brain's ability to autoregulate, what nursing assessment information most clearly indicates the highest patient risk?
A) Pulmonary adventitious sounds
B) Capillary refill less than 2 seconds
C) Blood pressure consistently elevated
D) Pain at 8 on 0-to-10 scale
C) Blood pressure consistently elevated
key word "autoregulate"
A patient with a skull fracture has a positive halo sign. What does this sign indicate?
A) Fracture of the anterior fossa
B) Presence of a basilar skull fracture
C) Impingement of cranial nerves
D) Cerebrospinal fluid leak
D) Cerebrospinal fluid leak
The nurse is performing a physical examination on a patient with neurologic disease. What finding from the examination is the most indicative of diminished cerebral hemisphere functioning?
A) Deteriorating level of consciousness
B) Positive Romberg test
C) Unequal pupillary response
D) Glasgow Coma Scale score of 15
A) Deteriorating level of consciousness
Three weeks after a viral illness, a patient has an onset of weakness in the lower extremities that is progressing to the arms. The patient is admitted to the CCU with a diagnosis of rapidly progressing Guillain-Barré syndrome. What is the nursing care priority?
A) Monitor respiratory system closely.
B) Prevent hazards of immobility.
C) Provide emotional support for patient and family.
D) Control musculoskeletal pain.
A) Monitor respiratory system closely
A patient with a traumatic brain injury is at high risk for a secondary brain injury. What is the best nursing explanation of a secondary brain injury?
A) Result of a repeated assault incident
B) From a penetrating gunshot wound
C) Trauma inflicted by another person
D) Cerebral edema and ischemia
D) Cerebral edema and ischemia
A patient was struck in the jaw and had hyperextension of the cervical spine. If the patient has central cord syndrome, what would the nurse most expect?
A) Full loss of motor function below the lesion
B) Ipsilateral increased cutaneous pain at the lesion
C) Arm paralysis with intact motor function in the legs
D) Full motor paralysis and loss of touch sensation below the lesion
C) Arm paralysis with intact motor function in the legs
usually results from hyperextension of neck
A patient is suspected of having injury to his carotid artery following trauma to his neck after engaging in a fight during a hockey game. Which diagnostic test would be most effective in investigating this injury?
A) Computed tomography (CT)
B) Magnetic resonance imaging (MRI)
C) Electroencephalogram (EEG)
D) Cerebral angiography
D) Cerebral angiography
An inexperienced nurse who is new to the ICU is examining the eyes of a comatose patient with traumatic brain injury who is on a ventilator. In doing so, she turns the patient's head sharply to one side. After she is finished, she leaves the patient's head turned to the side. A more experienced nurse sees this and cautions the new nurse not to turn the patient's head so sharply or leave it in that position. What is the best rationale for the more experienced nurse's admonition?
A) Compression of the jugular vein leading to increased intracranial pressure
B) Lack of a patent airway
C) Lack of dignity for the patient
D) Cramping of neck muscles
A) Compression of the jugular vein leading to increased intracranial pressure
A patient who was in a motor vehicle accident struck her forehead on the windshield of her car after crashing into the back of another car. Given this mechanism of injury, which regions of the brain are most likely to be injured? Select all that apply.
A) Frontal lobes
B) Parietal lobes
C) Occipital lobes
D) Temporal lobes
E) Diencephalon
F) Medulla oblongata
A) Frontal lobes
C) Occipital lobes
While assessing motor function, the nurse applies pressure to a toenail. What patient response is most normal?
A) Extension of both feet
B) Flexion of knee and ankle
C) Extension of one or both arms
D) Kicking the nurse's hand away
D) Kicking the nurse's hand away
A patient has just been diagnosed with Guillain-Barré syndrome and is experiencing ascending, symmetrical muscle weakness and paralysis. Which nursing intervention could best help prevent complications of immobility?
A) Assess strength of neck flexor muscles.
B) Promote use of antiembolism stockings.
C) Assist with plasmapheresis treatment.
D) Administer intravenous immunoglobulin.
B) Promote use of antiembolism stockings.
A patient with an acute brain injury is receiving IV mannitol, an osmotic diuretic. If this medication is effective, what does the nurse expect?
A) Increased cerebral perfusion pressure
B) Increased serum osmolarity above 320 mOsm
C) Reduction of Glasgow Coma Scale values
D) Development of fixed and dilated pupils
A) Increased cerebral perfusion pressure
CPP=MAP-ICP
A patient with a mild spinal cord injury becomes light-headed every time she attempts to rise from her bed. At rest, her heart rate and blood pressure are normal. All of her motor, sensory, reflex, and autonomic functions are intact. The nurse recognizes which condition in this patient?
A) Spinal shock
B) Neurogenic shock
C) Orthostatic hypotension
D) Central cord syndrome
C) Orthostatic hypotension
A patient is in the emergency department being treated for an ischemic stroke. What is the nursing priority of care?
A) Refer for rehabilitation care.
B) Initiate fibrinolysis within 3 hours.
C) Initiate intravenous glucose therapy.
D) Administer 100% oxygen by mask.
B) Initiate fibrinolysis within 3 hours.
A patient with traumatic brain injury is experiencing cerebral edema, which has led to severely elevated intracranial pressure. He has increased pulse pressure, decreased heart rate, and an irregular respiratory pattern. He has lost consciousness and demonstrates bilateral pupillary dilation. The nurse recognizes that these symptoms point to which condition?
A) Central herniation syndrome
B) Uncal herniation syndrome
C) Cerebrovascular injury
D) Diffuse axonal injury
A) Central herniation syndrome
The patient has a depressed skull fracture resulting in a tear of the dura mater. What nursing intervention is most directed at preventing a significant complication of this particular injury?
A) Elevating the head of the bed to 15 degrees
B) Giving supplemental oxygen by mask
C) Ensuring compliance with hand hygiene protocols
D) Obtaining consent for surgical repair of fracture
C) Ensuring compliance with hand hygiene protocols
Following a lumbar puncture for CSF analysis, a patient with elevated intracranial pressure develops a headache, nuchal rigidity, fever, and difficulty voiding. What intervention should the nurse expect?
A) Administration of IV fluids
B) Administration of antibiotic
C) Injection of blood into the dura
D) Cardiopulmonary resuscitation
C) Injection of blood into the dura
The patient has an intracranial pressure monitor. After the patient returns from a computed tomography (CT) scan of the head, the nurse notices that the patient's intracranial pressure is significantly lower than before the scan. What nursing action is most likely to identify a cause of this change?
A) Take vital signs.
B) Flush monitor tubing toward patient.
C) Relevel the transducer.
D) Drain cerebrospinal fluid.
C) Re-level the transducer.
Height of tragus of ear
After failing to effectively clear a patient's airway by having him cough, the nurse is now suctioning his airway. What complication related to suctioning should the nurse be aware of?
A) Bradycardia
B) Tachycardia
C) Hyperglycemia
D) Hypertension
A) Bradycardia
gag reflex stimulates vagal nerve
A patient presents to the ICU with a spinal cord injury at C3 and the following: loss of position sense, light touch, and vibratory sense below the level of the injury. However, the patient has retained all motor function and pain and temperature sensation. The nurse suspects that the injury has occurred on what portion of the spinal cord?
A) Central
B) Lateral
C) Anterior
D) Posterior
D) Posterior
A nurse is caring for a patient with an arteriovenous malformation (AVM). What symptom is the nurse most likely to observe in this patient?
A) Seizure
B) Headache
C) Intracranial pressure
D) Hemorrhage
D) Hemorrhage
Seek immediate medical attention if you notice any signs or symptoms of a brain AVM, such as seizures, headaches or other symptoms. A bleeding brain AVM is life-threatening and requires emergency medical attention.
A patient is demonstrating increased pulse pressure, decreased pulse, and irregular respiration. The nurse recognizes these symptoms of increased intracranial pressure and understands that the patient's autoregulation of cerebral blood flow in the brain has failed. Which of the following findings would be consistent with a failure of autoregulation of blood flow in the brain? Select all that apply.
A) Cerebral perfusion pressure of 40 mm Hg
B) Mean arterial pressure of 170 mm Hg
C) Systolic pressure of 120 mm Hg
D) Intracranial pressure of 35 mm Hg
A) Cerebral perfusion pressure of 40 mm Hg
B) Mean arterial pressure of 170 mm Hg
D) Intracranial pressure of 35 mm Hg
A patient with a suspected skull fracture is observed to have raccoon eyes, or bilateral periorbital bruising. What other symptom does the nurse expect?
A) Positive Battle's sign
B) Cerebrospinal fluid rhinorrhea
C) Cerebrospinal fluid otorrhea
D) Maxillarycranial separation
B) Cerebrospinal fluid rhinorrhea
A patient admitted to the ICU following a car accident in which she suffered multiple traumatic injuries. She has a fever of 101°F and complains of headache. When the physician tries to examine her eyes with a bright light, she jerks away. The nurse suspects meningeal irritation. What other signs would likely accompany this condition? Select all that apply.
A) Nuchal rigidity
B) Drainage of cerebrospinal fluid from the nose
C) Drainage of cerebrospinal fluid from the ear
D) Bruising over the mastoid areas
E) Pain in the neck when the thigh is flexed and the leg is extended at the knee
F) Involuntary flexion of the hips when the neck is flexed toward the chest
A) Nuchal rigidity
E) Pain in the neck when the thigh is flexed and the leg is extended at the knee
F) Involuntary flexion of the hips when the neck is flexed toward the chest
A 45-year-old man in the ICU is diagnosed with generalized myasthenia gravis. The physician is discussing treatment options with the patient. The nurse understands that which treatment option would likely be the most effective for this patient in the long term in terms of remission, overall survival, and clinical improvement?
A) Anticholinesterase
B) Plasmapheresis
C) Intravenous immunoglobulin
D) Thymectomy
D) Thymectomy
The patient has a spinal cord lesion at T1-T2. About an hour after being turned, the patient experiences a sudden throbbing headache accompanied by extreme blood pressure elevation and profound bradycardia. The patient has a very flushed face. What is the nursing priority?
A) Administer pain medication immediately.
B) Give intravenous beta-antagonist medication.
C) Turn on a fan.
D) Check Foley catheter for twisting or kinks.
D) Check Foley catheter for twisting or kinks.
Autonomic hyperreflexia most common cause: bladder distension