Chapter 22: Care of Patients with Head and Spinal Cord Injuries |DeWit: Medical Surgical Nursing: Concepts & Practice, 3rd Edition

MULTIPLE CHOICE 1. The nurse describes a concussion as a closed head injury in which: a. The brain tissue is bruised. b. No loss of consciousness occurs. c. There is amnesia related to the incident. d. There are no subsequent symptoms. ANS: C A concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks. PTS:1 DIF: Cognitive Level: Comprehension REF: 501, Figure 22-1 OBJ:1 (theory) TOP: Concussion: Pathophysiology KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. Why is the older adult more at risk for a cranial bleed following a head injury? a. The older adult’s brain is smaller, which allows for more movement inside the cranium. b. The older adult’s brain features fragile vessels more likely to rupture. c. The older adult’s brain contains less cerebrospinal fluid (CSF) to cushion the brain. d. The older adult’s brain has less flexible meninges to absorb impact. ANS: A The brain atrophies with age and does not take up as much space in the cranial vault. This change allows for more movement and more potential for torn vessels and contusions on the brain when an accident occurs that involves a head injury. PTS: 1 DIF: Cognitive Level: Comprehension REF: 501, Older Adult Care Points OBJ: 6 (theory) TOP: Cranial Bleed: Older Adult KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 3. The emergency room nurse is assessing a newly admitted patient with a head injury. The nurse observes clear drainage from the nose. Which action should the nurse perform first? a. Document the presence of rhinorrhea. b. Inform the physician of the assessment. c. Test the fluid with a Dextrostix. d. Tape a drip pad under the nose. ANS: C Head injury symptoms may include rhinorrhea (fluid from the nose) or otorrhea (fluid from the ear), among many others. Rhinorrhea and otorrhea should be tested to determine if there is a cerebrospinal fluid (CSF) leak. Testing with a Dextrostix will determine whether glucose is present; the presence of glucose indicates CSF. Documentation, informing the physician, and applying a drip pad under the nose are actions that should occur after confirmation of the fluid type. PTS:1 DIF: Cognitive Level: Analysis REF: 502 OBJ:1 (theory) TOP: Rhinorrhea KEY: Nursing Process Step: Implementation MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential 4. In assessing the patient with a significant right intracerebral hemorrhage, the nurse anticipates that the patient will demonstrate which signs? a. Left-sided hemiplegia with dilated right pupil b. Right-sided hemiplegia with brisk right pupil response c. Bilateral motor hemiplegia with bilaterally dilated pupils d. Left-sided hemiplegia and bilateral ANS: A An acute intracerebral bleed causing hematoma formation is accompanied by unconsciousness, hemiplegia on the contralateral (opposite) side, and a dilated pupil on the ipsilateral (same) side. However, the symptoms indicating a slow buildup of pressure within the skull are more subtle and less easily detected. PTS:1 DIF: Cognitive Level: Application REF: 502 OBJ:2 (theory) TOP: Closed Head Injury: Assessment KEY: Nursing Process Step: Assessment MSC: NCLEX: Physiological Integrity: Physiological Adaptation 5. The nurse is caring for an older adult patient who was admitted to the hospital following a closed head injury that resulted in a 5-minute period of unconsciousness. The nurse most carefully monitors the patient for which change?