NRSG 357 Exam 3 Questions and Answers with complete solutions

What does SCI stand for? A. Susceptible Cord Infection B. Super Comfy Injection C. Superior Cord Infarct D. Spinal Cord Injury - ANSWER D. Spinal Cord Injury True or False: Primary SCI is the initial disruption of axons; Secondary SCI is the ongoing, progressive damage due to ischemia, hypoxia, micro-hemorrhage, and edema. - ANSWER True A client is admitted to the emergency department with SCI at the level of T2. Which finding is of MOST concern to the nurse? A. Loss of motor and sensory function in arms and legs B. BP of 92/60 mm Hg C. Heart rate of 42 bpm D. SpO2 of 92% - ANSWER C. Heart rate of 42 bpm What causes an initial incomplete SCI to result in complete cord damage? A. Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury B. Edematous compression of the cord above the level of the injury C. Continued trauma to the cord resulting from damage to stabilizing ligaments D. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites - ANSWER D. Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites The nurse knows that a client suffering from complete paralysis from the waist down would have the condition of which of the following? A. Hemiparesis B. Paraparesis C. Paraplegia D. Hemiplegia - ANSWER C. Paraplegia Use of Glasgow Coma Scale (GCS) provides a relatively objective assessment of Level of Consciousness (LOC). What are the Three functions assessed? A. Verbal response, eye opening, motor response B. Eye opening, motor response, sensation C. Verbal response, pupil reaction, motor response D. Pupil reaction, orientation, sensation - ANSWER A. Verbal response, eye opening, motor response When the nurse applies painful stimulus to the nailbeds of and unconscious patient, the patient responds with internal rotation, adduction and flexion of the arms. The nurse documents this finding as: A. Flexion withdrawal B. Decorticate posturing C. Decerebrate posturing D. Localization of pain - ANSWER B. Decorticate posturing What is the normal value range of Intracranial Pressure (ICP)? A. 5-15 mm Hg B. 15-25 mm Hg C. 25 mm Hg D. 5 mm Hg - ANSWER A. 5-15 mm Hg What type of brain injury occurs due to swelling or impaired blood flow to the area of the injury (i.e. Increased Intracranial pressure, infection, ischemia, hypoxia) A. Primary Injury B. Secondary Injury C. Focal Injury D. Diffuse Axonal Injury - ANSWER B. Secondary Injury Complication which results from bleeding between the skull and dura mater - ANSWER Epidural Hematoma Complication which results from bleeding between the dura mater and arachnoid layer - ANSWER Subdural Hematoma Complication which results from bleeding within the brain tissue - ANSWER Intracerebral Hematoma The patient with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would AVOID which of the following measures to minimize the risk of recurrence? A. Strict adherence to a bowel retraining program B. Keeping the linen wrinkle-free under the patient C. Preventing unnecessary pressure of the lower limbs D. Limiting bladder catheterization to once every 12 hours - ANSWER D. Limiting bladder catheterization to once every 12 hours A patient has an incomplete left spinal cord lesion at the level of T7, resulting in Brown-Sequard syndrome. Which nursing action should be included in the plan of care? A. Assessment of the patient fro right arm weakness B. Assessment of the patient for increased right leg pain C. Positioning the patient's left leg, when turning the patient D. Teaching the patient to look at the right leg to verify its position - ANSWER C. Positioning the patient's left leg when turning the patient - Rare neurological condition - characterized by weakness or paralysis on one side of body and a loss of sensation on the opposite side - Incomplete spinal cord injury syndrome - May be caused by spinal cord tumor, trauma, ischemia, or infectious INFO NOT ON EXAM The nurse will explain to the patient who has a T2 spinal cord transection injury that A. Function of both arms should be retained B. Total loss of respiratory function may occur C. Use of the shoulders will be limited D. Tachycardia is common with this type of injury - ANSWER A. Function of both arms should be retained - Should not reach C4 level, so won't effect diaphragm or breathing - Bradycardia is common, not tachycardia A patient with paraplegia resulting from a T9 spinal cord injury has a neurogenic reflexic bladder. Which action will the nurse include in the plan of care? A. Assist the patient to the toilet every 2 hours B. Teach the patient the Crede method C. Catheterize for residual urine after voiding D. Instruct the patient how to self-catheterize - ANSWER D. Instruct the patient how to self-catheterize - Should be catheterized at regular intervals When the nurse is developing a rehabilitation plan for a 30 year old patient with a C6 spinal cord injury, an appropriate goal is that the patient will be able to A. Turn and reposition independently when in bed B. Push a manual wheelchair on a flat surface C. Drive a car with powered hand controls D. Transfer independently to and from a wheelchair - ANSWER B. Push a manual wheelchair on a flat surface - At C6, patient can still use arms, but don't have adequate flexion of fingers and thumbs causing inability to grasp with their hands A patient is admitted with dermal ulcers who has a history of a T3 spinal cord injury tells the nurse, "I have a pounding headache and I feel sick to my stomach". Which action should the nurse take FIRST? A. Assess the BP B. Give the prescribed antiemetic C. Notify the health care provider D. Check for a fecal impaction - ANSWER A. Assess the BP - Autonomic dysreflexia - Hypertension The nurse has completed discharge instructions for the patient with application of a halo device. The nurse determine that the patient needs further clarification of the instructions if the patient states that he or she will: A. Use a straw for drinking B. Drive only during the daytime C. Use caution because the device alters balance D. Wash the skin daily under the lamb's wool liner of the vest - ANSWER B. Drive only during the daytime - Cannot turn their head Which of the following clinical manifestation would the nurse interpret as representing neurogenic shock in a patient with acute spinal cord injury? A. Bradycardia B. Hypertension C. Neurogenic spasticity D. Bounding pedal pulses - ANSWER A. Bradycardia - & hypotension Patient is being admitted with a spinal cord transection at C7. Which of the following assessments take priority upon the patient's arrival? A. Reflexes B. Bladder function C. Blood pressure D. Pupillary response E. Respirations - ANSWER E. Respirations In which order will the nurse preform the following actions when caring for a patient with possible C5 spinal cord trauma who is admitted to the ED? - Infuse NS at 150 mL/hour - Monitor cardiac rhythm and BP - Administer O2 using a nonrebreather mask - Immobilize the patient's head, neck, and spine - Transfer the patient to radiology for spinal CT - ANSWER 1. Immobilize the patient's head, neck, and spine 2. Administer O2 using a nonrebreather mask 3. Monitor cardiac rhythm and BP 4. Infuse NS at 150 mL/hour 5. Transfer the patient to radiology for spinal CT A patient with a spinal cord injury has a post-void residual of 340 mL. The best action by the nurse would be to: A. Restrict fluids B. Apply bladder pressure C. Catheterize D. Give Tolterodine or oxybutynin - ANSWER C. Catheterize A patient with a spinal cord injury at T5 has decreased GI motility as evidenced by abdominal pain and distention and inability to pass flatus. Which nursing intervention is most appropriate for this patient? A. Assess the abdomen for bowel sounds B. Place the patient in high Fowler's position C. Ambulate the patient more frequently D. Obtain an order for nasogastric tube - ANSWER D. Obtain an order for nasogastric tube - what INTERVENTION A patient with a head injury has a blood pressure is 112/76 mm Hg and an intracranial pressure of 16 mm Hg. Which action by the nurse is appropriate? A.Document and continue to monitor the parameters. B. Elevate the head of the patient's bed. C. Notify the health care provider about the assessments. D. Check the patient's pupillary response to light - ANSWER A. Document and continue to monitor the parameters Normal CPP: 60-100 mmHg Normal ICP: 5-15 mmHg Saeed, a registered nurse, is part of the emergency medical response team in the small community where he lives. He is first on the scene of an accident in which an unbelted driver hit a telephone pole at high speed. Which of the following assessments of the victim should he make first? A. Is the person breathing? B. Is the person aware of where he is? C. Is the person able to move his legs? D. Does the person have a pulse? - ANSWER A. Is the person breathing? ABCs! The GCS score for your client with a risk for increased intracranial pressure has been stable at 12 for the last 6 hours. This time you rate him at 9. Which of the following have you noted and what does it mean? A. He is less responsive, a sign that his intracranial pressure may be increasing B. He is more responsive, a sign that he may be improving C. His pupils are fixed and dilated, an ominous sign D. He does not move or make sounds, which may mean he got too much pain medication - ANSWER A. He is less responsive, a sign that his intracranial pressure may be increasing - GCS does not include pupil response - If he makes no sounds or movement, his GCS will be lower than 9 The nurse recognized the presence of Cushing's Triad in the patient with which of the following vital sign changes? A. Increased pulse, irregular respirations, increased B/P B. Decreased pulse, increased respirations, decreased systolic B/P C. Decreased pulse, irregular respirations, widened pulse pressure D. Increased pulse, decreased respirations, widened pulse pressure - ANSWER C. Decreased pulse, irregular respirations, widened pulse pressure At which of the following time points following a head injury does death generally occur? (Select all that apply). A. Within 3 weeks of the injury. B. Immediately following the injury. C. 6-12 months following the injury. D. Within 2 hours of the initial injury. E. 12 months or more following the initial injury. - ANSWER A. Within 3 weeks of the injury. B. Immediately following the injury. D. Within 2 hours of the initial injury. - The majority of deaths after a head injury occur immediately after the injury, either from the direct head trauma or from massive hemorrhage and shock. - Deaths occurring within a few hours of the trauma are caused by progressive worsening of the brain injury (increasing ICP, edema) or internal bleeding - Deaths occurring 3 weeks or more after the injury result from multisystem failure. - Expert nursing care in the weeks after the injury is crucial in decreasing the mortality risk and in optimizing patient outcomes. - Primary Injury: occurs at time of injury initial impact (blunt force, MVA, etc). The displacement, bruising or damage that occurs with initial injury - Secondary Injury is the resulting hypoxia, ischemia, hypotension, edema, or increased ICP that occurs as a result of the initial injury. Which of the following is a compound skull fracture: A. A simple linear or depressed skull fracture without fragmentation, and generally occurs with low to moderate impact injury B. Multiple linear fractures with fragmentation of bone, generally occurring with direct or high-momentum impact. C. A depressed fracture with scalp laceration and extends into intracranial cavity, generally associated with sever head injury. - ANSWER C. A depressed fracture with scalp laceration and extends into intracranial cavity, generally associated with sever head injury. A = simple B = comminuted fracture C = compound fracture Which of the following are Focal Injuries: (select all that apply) A. Diffuse Axonal injury B. Contusion C. Laceration D. Concussion E. Epidural hematoma - ANSWER B, C, E - Diffuse (generalized) injuries include concussion and diffuse axonal injury - Focal (local) injuries include lacerations, contusions, hematoma, and cranial nerve injuries Which injury is generally more severe? A. Coup injury B. Contrecoup injury - ANSWER B. Contrecoup injury - Damage from coup-contrecoup injury occurs when the brain moves inside the skull due to high-energy or high-impact injury mechanisms. -Contusions or lacerations occur both at the site of the direct impact of the brain on the skull (coup) and at a secondary area of damage on the opposite side away from injury (contrecoup), leading to multiple contused areas. **Contrecoup injuries tend to be more severe, and overall patient prognosis depends on the amount of bleeding around the contusion site. Which of the following clinical manifestations would the nurse expect to find in a patient who suffered a Basilar Skull Fracture? (Select all that apply) A. Periorbital edema (Raccoon eyes) B. Rhinorrhea C. Otorrhea D. Post-auricle ecchymosis (Battle's sign) E. hemiparesis - ANSWER A, B, C, D - Individuals with Basilar Skull Fracture may also manifest bulging tympanic membrane (CSF or blood) auditory changes, loss or impaired hearing, vertigo, paralysis The nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? A. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. B. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. D. The 62-year-old client diagnosed with CVA who has expressive aphasia. - ANSWER C. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. - The Glasgow Coma Scale is used to determine a client's response to stimuli such as Eye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed first. A resident in a long term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with steristrips. Which signs or symptoms would warrant transferring the resident to the emergency department? A. A 4 centimeter area of bright red drainage on the dressing. B. A weak pulse, shallow respirations, and cool pale skin. C. Pupils that are equal, react to light, and accommodate. D. Complaints of a headache that's resolved with medication. - ANSWER B. A weak pulse, shallow respirations, and cool pale skin. - These s/sx indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention Which of the following are most likely associated with delirium? (Select all that apply) A. Insidious onset over months to years B. Acute onset of change in mental status C. Associated with use of medications with anticholinergic effect D. Mental status potentially returns to pre illness baseline E. No perceptual disturbances (i.e., hallucinations) until later disease - ANSWER A = dementia B = delirium C = delirium D = delirium E = dementia The most common trigger for delirium is: A. Alcohol withdrawal B. Fecal impaction C. Head trauma D. Acute infection - ANSWER D. Acute infection Medications that commonly contribute to delirium include all of the following except: A. first-generation antihistamines B. Cardioselectivebeta-adrenergic antagonists C. Opioids D. Benzodiazepines - ANSWER B. Cardioselectivebeta-adrenergic antagonists