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Questions and Answers
Which nursing intervention is appropriate to prevent a deep vein thrombosis (DVT) in a patient with spinal cord injury?
Which nursing intervention is appropriate to prevent a deep vein thrombosis (DVT) in a patient with spinal cord injury?
What action can best prevent contractures in a patient with spinal cord injury?
What action can best prevent contractures in a patient with spinal cord injury?
What is the best rationale for the physician's orders regarding head positioning in a patient with a head injury?
What is the best rationale for the physician's orders regarding head positioning in a patient with a head injury?
What assessment finding should be expected in a patient with a T2 injury in spinal shock?
What assessment finding should be expected in a patient with a T2 injury in spinal shock?
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What aspect of a patient's status can be gauged by reviewing the trend of scores on the Glasgow Coma Scale (GCS)?
What aspect of a patient's status can be gauged by reviewing the trend of scores on the Glasgow Coma Scale (GCS)?
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What injury would be suspected in a 13-year-old patient who regained consciousness after being unconscious and cannot remember the event?
What injury would be suspected in a 13-year-old patient who regained consciousness after being unconscious and cannot remember the event?
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At what point in the patient's care should a neurologic flow chart be used?
At what point in the patient's care should a neurologic flow chart be used?
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Why is autonomic dysreflexia considered an emergency?
Why is autonomic dysreflexia considered an emergency?
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What principle should guide the care team's decision regarding the removal of a urinary catheter in a patient with spinal cord injury?
What principle should guide the care team's decision regarding the removal of a urinary catheter in a patient with spinal cord injury?
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What physical assessment findings are suggestive of a basilar skull fracture? (Select all that apply)
What physical assessment findings are suggestive of a basilar skull fracture? (Select all that apply)
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What nursing diagnosis should the nurse associate with the necessary endotracheal intubation for a client with a high cervical spinal cord injury?
What nursing diagnosis should the nurse associate with the necessary endotracheal intubation for a client with a high cervical spinal cord injury?
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What clinical manifestations would the nurse expect in a client with autonomic dysreflexia?
What clinical manifestations would the nurse expect in a client with autonomic dysreflexia?
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Which clinical manifestation would suggest that a client may be experiencing increased brain compression causing brain stem damage?
Which clinical manifestation would suggest that a client may be experiencing increased brain compression causing brain stem damage?
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What is the priority intervention for a client suspected of having an epidural hematoma?
What is the priority intervention for a client suspected of having an epidural hematoma?
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What is the most appropriate action for a nurse caring for a client with neurogenic shock?
What is the most appropriate action for a nurse caring for a client with neurogenic shock?
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What event is recognized as the most common cause of spinal cord injuries?
What event is recognized as the most common cause of spinal cord injuries?
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What are the most likely possible causes of death for a client with a spinal cord injury?
What are the most likely possible causes of death for a client with a spinal cord injury?
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What appropriate nursing interventions should be taken if increased ICP is suspected in a head injury patient?
What appropriate nursing interventions should be taken if increased ICP is suspected in a head injury patient?
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What nursing care should include for a client with a nondepressed skull fracture?
What nursing care should include for a client with a nondepressed skull fracture?
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What aspect of the client's current health status is most likely to have precipitated an episode of autonomic dysreflexia?
What aspect of the client's current health status is most likely to have precipitated an episode of autonomic dysreflexia?
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What supportive priority measure should be anticipated for a client with a brain injury?
What supportive priority measure should be anticipated for a client with a brain injury?
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What is the best intervention for preventing injury in an agitated client?
What is the best intervention for preventing injury in an agitated client?
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What should the nurse do first for a client with a C5 spinal cord injury reporting a severe headache?
What should the nurse do first for a client with a C5 spinal cord injury reporting a severe headache?
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What should the nurse suspect with sudden depression of reflex activity in the spinal cord below the level of injury?
What should the nurse suspect with sudden depression of reflex activity in the spinal cord below the level of injury?
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What specific measures are anticipated to be initiated for a client at risk for post-traumatic seizures?
What specific measures are anticipated to be initiated for a client at risk for post-traumatic seizures?
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What complication could be indicated by a severe headache with a rapid onset in a client with a spinal cord injury?
What complication could be indicated by a severe headache with a rapid onset in a client with a spinal cord injury?
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What cardinal signs of brain death should be recognized during assessment?
What cardinal signs of brain death should be recognized during assessment?
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What priority nursing action should be implemented if a traction pin becomes detached?
What priority nursing action should be implemented if a traction pin becomes detached?
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What will be the primary goal of initial therapy for a 6-year-old child suspected of having a brain injury?
What will be the primary goal of initial therapy for a 6-year-old child suspected of having a brain injury?
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Which primary neuroimaging diagnostic tool would be used to evaluate the brain structure for a suspected diffuse axonal injury?
Which primary neuroimaging diagnostic tool would be used to evaluate the brain structure for a suspected diffuse axonal injury?
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Which assessment finding would rule out discharging a 13-year-old client diagnosed with a concussion?
Which assessment finding would rule out discharging a 13-year-old client diagnosed with a concussion?
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Due to the age of an 82-year-old client after a fall, what complication is he at increased risk for?
Due to the age of an 82-year-old client after a fall, what complication is he at increased risk for?
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Which medication would best allow an accurate assessment of a client's neurological status in the ICU with traumatic brain injury?
Which medication would best allow an accurate assessment of a client's neurological status in the ICU with traumatic brain injury?
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What action should the nurse implement to address sleep deprivation in a client with head injuries?
What action should the nurse implement to address sleep deprivation in a client with head injuries?
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How can the nurse best facilitate family coping for a client with traumatic brain injury?
How can the nurse best facilitate family coping for a client with traumatic brain injury?
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What are prominent risk factors for spinal cord injuries (SCI)? (Select all that apply)
What are prominent risk factors for spinal cord injuries (SCI)? (Select all that apply)
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What action should the nurse perform when a football player is laying immobile on the field after a head injury?
What action should the nurse perform when a football player is laying immobile on the field after a head injury?
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What medication is expected to be prescribed to control muscle spasticity following a spinal cord injury?
What medication is expected to be prescribed to control muscle spasticity following a spinal cord injury?
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How can the nurse best address the risk for impaired skin integrity in a client with a T1 spinal cord injury?
How can the nurse best address the risk for impaired skin integrity in a client with a T1 spinal cord injury?
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How can the nurse best address a client's risk for orthostatic hypotension after several hypotensive episodes?
How can the nurse best address a client's risk for orthostatic hypotension after several hypotensive episodes?
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What aspect of the neurologic and functional status should the nurse consider for a client with a spinal cord injury at the level of C4?
What aspect of the neurologic and functional status should the nurse consider for a client with a spinal cord injury at the level of C4?
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Which action should the nurse implement to prevent pressure injuries in an unconscious client with a traumatic brain injury?
Which action should the nurse implement to prevent pressure injuries in an unconscious client with a traumatic brain injury?
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Which nursing action is most appropriate for a client exhibiting early signs of disuse syndrome from spinal cord injury?
Which nursing action is most appropriate for a client exhibiting early signs of disuse syndrome from spinal cord injury?
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When should the nurse remove and reapply splints for a client at risk of developing foot drop?
When should the nurse remove and reapply splints for a client at risk of developing foot drop?
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What principle should guide the care team's decision regarding the removal of a urinary catheter in a male client with spinal cord injury?
What principle should guide the care team's decision regarding the removal of a urinary catheter in a male client with spinal cord injury?
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What potential complications should be monitored for in a client with spinal cord injury? (Select all that apply)
What potential complications should be monitored for in a client with spinal cord injury? (Select all that apply)
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How can the nurse best prevent the risk of muscle spasticity in a client with spinal cord injury?
How can the nurse best prevent the risk of muscle spasticity in a client with spinal cord injury?
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Which nursing diagnosis would the nurse prioritize in the immediate care of a client with a C4 spinal cord injury?
Which nursing diagnosis would the nurse prioritize in the immediate care of a client with a C4 spinal cord injury?
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What is the priority intervention for a patient suspected of having an epidural hematoma after a fall?
What is the priority intervention for a patient suspected of having an epidural hematoma after a fall?
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Study Notes
Basilar Skull Fracture Indicators
- Epistaxis (nosebleed) is a common sign.
- Bruising over the mastoid (Battle sign) indicates possible injury.
Endotracheal Intubation Nursing Diagnosis
- Risk for injury is critical due to potential neck flexion causing cervical injury.
Autonomic Dysreflexia Symptoms
- Characterized by bradycardia and hypertension, along with headache and sweating.
Increased Intracranial Pressure (ICP) Manifestations
- Hyperthermia can indicate severe brain stem damage and increased metabolic demand.
Epidural Hematoma Priority Intervention
- Immediate surgical intervention with skull openings is required to alleviate pressure and control bleeding.
Neurogenic Shock Management
- Risk for low blood pressure necessitates preparations for interventions to increase BP.
Common Cause of Spinal Cord Injuries
- Motor vehicle accidents are the leading cause of spinal cord injuries.
Major Causes of Death in Spinal Cord Injury Patients
- Focus on preventing pneumonia, pulmonary embolism, and sepsis through assisted coughing and compression devices.
Nursing Interventions for Head Injury with Increased ICP
- Administer benzodiazepines if agitation occurs, and maintain head elevation to reduce pressure.
Nondepressed Skull Fracture Care
- Watchful waiting and close monitoring are typical, surgical intervention is rarely needed.
Autonomic Dysreflexia Triggers
- A blocked urinary catheter is a common cause of autonomic dysreflexia episodes in spinal injury patients.
Brain Injury Supportive Measures
- Cervical and spinal immobilization is essential until cervical spine injury is ruled out.
Injury Prevention in Agitated Clients
- Padding side rails is the best option to prevent self-injury without using restraints.
Headache in C5 Spinal Cord Injury
- A severe headache may indicate autonomic dysreflexia; check catheter patency first.
Signs of Brain Death
- Cardinal signs include coma, apnea, and absence of brain stem reflexes.
Halo Traction Pin Detachment Response
- Notify the neurosurgeon immediately while stabilizing the head in a neutral position.
Treatment Goal for Unresponsive Children with Head Injuries
- Preserve brain homeostasis and prevent secondary brain injury as the primary therapy goal.
Neuroimaging for Diffuse Axonal Injury
- Magnetic resonance imaging (MRI) is the preferred tool for assessing brain structure.
Concussion Note
- Classify head injuries, like concussions in children, with appropriate observation and management strategies.### Assessment Findings and Discharge
- Slurred speech indicates potential serious trauma, warranting further assessment.
- Headache and localized pain are typical in concussions and do not necessarily postpone discharge.
- Visible fatigue can be expected after head injuries but does not rule out discharge.
Risk Factors in Older Adults
- Increased risk for hematomas in older adults due to more adherent dura and common use of anticoagulants.
- Stroke and other complications are less likely as direct outcomes of falls in this demographic.
Neurological Assessment Medications
- Propofol is preferred for clients with TBI; its rapid onset allows accurate neurological assessments.
- Midazolam and Lorazepam can lead to prolonged sedation, compromising assessment.
Care for Sleep Deprivation
- Cluster nursing activities to minimize nighttime disturbances and promote uninterrupted sleep.
- Avoid benzodiazepines for sleep, as they are not practical or safe for this scenario.
Family Support in TBI Care
- Assisting the family in setting short-term goals enhances coping.
- Avoid downplaying concerns by stating the client could have fared worse, or emphasizing acceptance of limitations prematurely.
Spinal Cord Injury (SCI) Risk Factors
- Prominent risk factors for SCI include young age, male gender, and substance use (alcohol/drugs).
- Ethnicity and frequent travel are not established risk factors.
Immediate Care Following Spinal Injury
- Ensuring the injured player is not moved is critical to prevent further injury while waiting for medical assistance.
- Immobilize the head and neck to maintain a neutral position.
Managing Muscle Spasticity in SCI
- Baclofen is commonly prescribed to manage muscle spasms associated with spinal cord injuries.
- Dexamethasone is for inflammation; Mannitol reduces cerebral edema; Phenobarbital is an anticonvulsant.
Skin Integrity and SCI
- Frequent repositioning is essential to prevent pressure ulcers; a high-protein diet aids healing but doesn't stop skin breakdown.
- Careful assessment of skin integrity should occur every 8 hours for clients at high risk.
Orthostatic Hypotension in SCI
- Closely monitor blood pressure before and during position changes to prevent hypotensive episodes.
- Prolonged bed rest is not advisable.
Prioritizing Nursing Diagnoses
- In C4 spinal injuries, the priority nursing diagnosis relates to ineffective breathing due to intercostal muscle weakness.
- Other diagnoses are relevant but less critical initially.
Emergency Interventions for Head Injuries
- An epidural hematoma requires emergency craniotomy to alleviate increased intracranial pressure and manage bleeding.
- Antihypertensives and anticoagulants are not prioritized in acute settings.
Preventing Deep Vein Thrombosis (DVT)
- Applying thigh-high elastic stockings is a primary intervention to promote venous return and prevent DVT.
- Fluid restrictions and certain medications may exacerbate clot risks.
Preventing Contractures in SCI
- Initiating passive range-of-motion exercises as soon as possible after injury is crucial to avoid contractures.
- Repositioning alone is insufficient for prevention.
Positioning for ICP Management
- Elevating the head and avoiding neck flexion prevents impeded venous outflow, essential in managing ICP.
- Proper positioning supports cranial blood flow dynamics.
Understanding Spinal Shock
- In spinal shock, all reflexes are absent, and limbs are flaccid; this condition is transitional following a spinal cord injury.
Glasgow Coma Scale (GCS)
- GCS measures level of consciousness through eye opening, verbal response, and motor response.
Trauma Assessment for Children
- Assessment and treatment protocols in children's cases of head trauma differ and should be addressed with particular attention to pediatric considerations.### Concussion Types and Diagnosis
- Grade 3 concussion involves loss of consciousness lasting seconds to minutes, often associated with temporal lobe involvement causing amnesia.
- Neurologic flow charts are initiated as soon as the initial assessment of a traumatic brain injury is completed, and not at the beginning of each shift or when deterioration occurs.
- Diffuse axonal injury (DAI) results from shearing and rotational forces, affecting axons throughout the brain, while a cerebral contusion occurs from severe acceleration-deceleration forces leading to localized brain bruising.
Autonomic Dysreflexia in Spinal Cord Injury
- Autonomic dysreflexia is a critical emergency due to sudden blood pressure increases, which can lead to increased intracranial pressure (ICP) or cerebral blood vessel rupture.
- It is essential to understand that autonomic dysreflexia does not directly damage nerve fibers but poses risks to vascular health.
Urinary Management in Spinal Cord Injury
- Removal of a urinary catheter in patients with spinal cord injuries must be handled with care, as urinary retention can lead to serious complications like bladder distention and autonomic dysreflexia.
- Patients with spinal cord injuries may need prolonged catheterization to manage urinary function effectively; normal elimination should only be pursued under careful consideration of the injury's level and the potential risks involved.
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Test your knowledge on the management of patients with neurologic trauma through this comprehensive set of flashcards. Focus on key physical assessment findings related to basilar skull fractures and other critical symptoms. Perfect for nursing students and healthcare professionals.
