Chapter 63 Management of Patients With Neurologic Trauma
1.After sustaining 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
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) C) Cyclobenzaprine (Flexeril)
B) Methylprednisolone (Solu-Medrol) D) Hydralazine hydrochloride (Apresoline)
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.
4.The nurse observing a patient with autonomic dysreflexia would expect which of the
following clinical manifestations?
A) Tachycardia and hypotension C) Tachycardia and hypertension
B) Bradycardia and hypertension D) Bradycardia and hypotension
, 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
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
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
1.After sustaining 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
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) C) Cyclobenzaprine (Flexeril)
B) Methylprednisolone (Solu-Medrol) D) Hydralazine hydrochloride (Apresoline)
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.
4.The nurse observing a patient with autonomic dysreflexia would expect which of the
following clinical manifestations?
A) Tachycardia and hypotension C) Tachycardia and hypertension
B) Bradycardia and hypertension D) Bradycardia and hypotension
, 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
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
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
