Chapter 39, Caring for Clients With Head and Spinal Cord Trauma.
1. The nurse is caring for a client with a head injury after a fall from a hayloft. Which of
the following indicates the presence of/or leaking of cerebral spinal fluid?
A) Change in the level of consciousness (LOC)
B) Signs of increased intracranial pressure (IICP)
C) Halo sign
D) Swelling
Ans: C
Feedback:
To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the
nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
Change in the LOC and signs of IICP are part of the neurologic assessment and do not
assist in detecting any CSF drainage. The presence of swelling does not assist in detecting
CSF drainage.
2. Which of the following types of hematoma results from venous bleeding with
blood gradually accumulating in the space below the dura?
A) Epidural
B) Subdural
C) Intracerebral
D) Cerebral
Ans: B
Feedback:
A subdural hematoma results from venous bleeding, with blood gradually accumulating
in the space below the dura. An epidural hematoma stems from arterial bleeding, usually
from the middle meningeal artery, and blood accumulation above the dura. An
intracerebral hematoma is bleeding within the brain that results from an open or closed
head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A
cerebral hematoma is bleeding within the skull.
3. You are caring for a client with a spinal cord injury. What test reveals the level of
spinal cord injury?
A) Radiography
B) Myelography
C) Neurologic examination
D) Computed tomography (CT) scan
Ans: C
Feedback:
A neurologic examination reveals the level of spinal cord injury. Radiography,
myelography, and a CT scan show the evidence of fracture or compression of one or
more vertebrae, edema, or a hematoma.
4. The nurse is admitting a client from the emergency department with a reported spinal
cord injury. What device would the nurse expect to be used to provide correct
vertebral
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, Chapter 39, Caring for Clients With Head and Spinal Cord Trauma.
alignment and to increase the space between the vertebrae in a client with spinal cord
injury?
A) Cervical collar
B) Cast
C) Traction with weights and pulleys
D) Turning frame
Ans: C
Feedback:
Traction with weights and pulleys is applied to provide correct vertebral alignment and to
increase the space between the vertebrae. A cast and a cervical collar are used to
immobilize the injured portion of the spine. A turning frame is used to change the client's
position without altering the alignment of the spine.
5.A client with impaired physical mobility has been hospitalized. What nursing intervention
helps reduce the potential for formation of thrombi and renal calculi in a client with
impaired physical mobility?
A) Provide a well-balanced diet.
B) Position the client.
C) Keep the client hydrated.
D) Help the client perform exercises.
Ans: C
Feedback:
The nurse should keep the client hydrated. Adequate hydration reduces the potential for
the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and
elements necessary for energy and to sustain cellular growth and repair. Positioning the
client helps avoid joint contractures and foot drop. Active and passive exercise
maintains joint flexibility and reduces muscle atrophy and atony.
6.A mother brings her 6-year-old to the emergency department (ED) after the child fell off
the bike. The physician diagnoses a concussion. The mother asks the nurse what a
concussion is. What should the nurse's response be?
A) “A concussion is a blow to the head that bruises the brain.”
B) “A concussion is a blow to the head that is hard enough for the brain to bounce off
the other side of the skull.”
C) “A concussion is a blow to the head that is minor and has no real consequences.”
D) “A concussion is a blow to the head that jars the brain, resulting in diffuse and
microscopic injury to the brain.”
Ans: D
Feedback:
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. A concussion results in diffuse and microscopic injury to the brain.
Options A, B, and C are incorrect because they give incorrect information to the mother.
Page 2
1. The nurse is caring for a client with a head injury after a fall from a hayloft. Which of
the following indicates the presence of/or leaking of cerebral spinal fluid?
A) Change in the level of consciousness (LOC)
B) Signs of increased intracranial pressure (IICP)
C) Halo sign
D) Swelling
Ans: C
Feedback:
To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the
nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice.
Change in the LOC and signs of IICP are part of the neurologic assessment and do not
assist in detecting any CSF drainage. The presence of swelling does not assist in detecting
CSF drainage.
2. Which of the following types of hematoma results from venous bleeding with
blood gradually accumulating in the space below the dura?
A) Epidural
B) Subdural
C) Intracerebral
D) Cerebral
Ans: B
Feedback:
A subdural hematoma results from venous bleeding, with blood gradually accumulating
in the space below the dura. An epidural hematoma stems from arterial bleeding, usually
from the middle meningeal artery, and blood accumulation above the dura. An
intracerebral hematoma is bleeding within the brain that results from an open or closed
head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A
cerebral hematoma is bleeding within the skull.
3. You are caring for a client with a spinal cord injury. What test reveals the level of
spinal cord injury?
A) Radiography
B) Myelography
C) Neurologic examination
D) Computed tomography (CT) scan
Ans: C
Feedback:
A neurologic examination reveals the level of spinal cord injury. Radiography,
myelography, and a CT scan show the evidence of fracture or compression of one or
more vertebrae, edema, or a hematoma.
4. The nurse is admitting a client from the emergency department with a reported spinal
cord injury. What device would the nurse expect to be used to provide correct
vertebral
Page 1
, Chapter 39, Caring for Clients With Head and Spinal Cord Trauma.
alignment and to increase the space between the vertebrae in a client with spinal cord
injury?
A) Cervical collar
B) Cast
C) Traction with weights and pulleys
D) Turning frame
Ans: C
Feedback:
Traction with weights and pulleys is applied to provide correct vertebral alignment and to
increase the space between the vertebrae. A cast and a cervical collar are used to
immobilize the injured portion of the spine. A turning frame is used to change the client's
position without altering the alignment of the spine.
5.A client with impaired physical mobility has been hospitalized. What nursing intervention
helps reduce the potential for formation of thrombi and renal calculi in a client with
impaired physical mobility?
A) Provide a well-balanced diet.
B) Position the client.
C) Keep the client hydrated.
D) Help the client perform exercises.
Ans: C
Feedback:
The nurse should keep the client hydrated. Adequate hydration reduces the potential for
the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and
elements necessary for energy and to sustain cellular growth and repair. Positioning the
client helps avoid joint contractures and foot drop. Active and passive exercise
maintains joint flexibility and reduces muscle atrophy and atony.
6.A mother brings her 6-year-old to the emergency department (ED) after the child fell off
the bike. The physician diagnoses a concussion. The mother asks the nurse what a
concussion is. What should the nurse's response be?
A) “A concussion is a blow to the head that bruises the brain.”
B) “A concussion is a blow to the head that is hard enough for the brain to bounce off
the other side of the skull.”
C) “A concussion is a blow to the head that is minor and has no real consequences.”
D) “A concussion is a blow to the head that jars the brain, resulting in diffuse and
microscopic injury to the brain.”
Ans: D
Feedback:
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. A concussion results in diffuse and microscopic injury to the brain.
Options A, B, and C are incorrect because they give incorrect information to the mother.
Page 2
