ICPhead injury NCLEX style questions

ICP/head injury NCLEX style questions ScienceMedicineEmergency Medicine Alix_VanderWiele Save Head Injury Practice Questions 37 terms LeMoyneFreeman Preview Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview Trauma/SCI/TBI/ICP NCLEX Questio...41 terms carterknw503Preview Spinal 26 terms ET0 The ED nurse is caring for a patient who has been brought in by ambulance after sustaining a fall at home. What physical assessment finding is suggestive of a basilar skull fracture?

• Epistaxis
• Periorbital edema
• Bruising over the mastoid
• Unilateral facial numbness

C An area of ecchymosis (bruising) may be seen over the mastoid (Battles sign) in a basilar skull fracture.A patient is brought to the trauma center by ambulance after sustaining a high cervical spinal cord injury 1 hours ago. Endotracheal intubation has been deemed necessary and the nurse is preparing to assist. What nursing diagnosis should the nurse associate with this procedure?

• Risk for impaired skin integrity
• Risk for injury
• Risk for autonomic dysreflexia
• Risk for suffocation

B If endotracheal intubation is necessary, extreme care is taken to avoid flexing or extending the patients neck, which can result in extension of a cervical injury. Intubation does not directly cause autonomic dysreflexia and the threat to skin integrity is a not a primary concern. Intubation does not carry the potential to cause suffocation.

A nurse is caring for a critically ill patient with autonomic dysreflexia. What clinical manifestations would the nurse expect in this patient?

• Respiratory distress and projectile vomiting
• Bradycardia and hypertension
• Tachycardia and agitation
• Third-spacing and hyperthermia

B Autonomic dysreflexia is characterized by a pounding headache, profuse sweating, nasal congestion, piloerection (goose bumps), bradycardia, and hypertension. It occurs in cord lesions above T6 after spinal shock has resolved; it does not result in vomiting, tachycardia, or third-spacing 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 suggest that the patient may be experiencing increased brain compression causing brain stem damage?

• Hyperthermia
• Tachycardia
• Hypertension
• Bradypnea

A Signs of increasing ICP include slowing of the heart rate (bradycardia), increasing systolic BP, and widening pulse pressure. As brain compression increases, respirations become rapid, BP may decrease, and the pulse slows further. A rapid rise in body temperature is regarded as unfavorable. Hyperthermia increases the metabolic demands of the brain and may indicate brain stem damage.A patient is brought to the ED by her family after falling off the roof. A family member tells the nurse that when the patient fell she was knocked out, but came to and seemed okay. Now she is complaining of a severe headache and not feeling well. The care team suspects an epidural hematoma, prompting the nurse to prepare for which priority intervention?

• Insertion of an intracranial monitoring device
• Treatment with antihypertensives
• Emergency craniotomy
• Administration of anticoagulant therapy

C An epidural hematoma is considered an extreme emergency. Marked neurologic deficit or respiratory arrest can occur within minutes. Treatment consists of making an opening through the skull to decrease ICP emergently, remove the clot, and control the bleeding. Anticoagulant therapy should not be ordered for a patient who has a cranial bleed. Insertion of an intracranial monitoring device may be done during the surgery, but is not priority for this patient.The staff educator is precepting a nurse new to the critical care unit when a patient with a T2 spinal cord injury is admitted. The patient is soon exhibiting manifestations of neurogenic shock. In addition to monitoring the patient closely, what would be the nurses most appropriate action?

• Prepare to transfuse packed red blood cells.
• Prepare for interventions to increase the patients BP.
• Place the patient in the Trendelenberg position.
• Prepare an ice bath to lower core body temperature.

B Manifestations of neurogenic shock include decreased BP and heart rate. Cardiac markers would be expected to rise in cardiogenic shock.Transfusion, repositioning, and ice baths are not indicated interventions.

An ED nurse has just received a call from EMS that they are transporting a 17-year-old man who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?

• Sports-related injuries
• Acts of violence
• Injuries due to a fall
• Motor vehicle accidents

D The most common causes of SCIs are motor vehicle crashes (46%), falls (22%), violence (16%), and sports (12%).A patient with spinal cord injury has a nursing diagnosis of altered mobility and the nurse recognizes the increased the risk of deep vein thrombosis (DVT). Which of the following would be included as an appropriate nursing intervention to prevent a DVT from occurring?

• Placing the patient on a fluid restriction as ordered
• Applying thigh-high elastic stockings
• Administering an antifibrinolyic agent
• Assisting the patient with passive range of motion (PROM) exercises

B It is important to promote venous return to the heart and prevent venous stasis in a patient with altered mobility. Applying elastic stockings will aid in the prevention of a DVT.Paramedics have brought an intubated patient to the ED following a head injury due to acceleration- deceleration motor vehicle accident.Increased ICP is suspected. Appropriate nursing interventions would include which of the following?

• Keep the head of the bed (HOB) flat at all times.
• Teach the patient to perform the Valsalva maneuver.
• Administer benzodiazepines on a PRN basis.
• Perform endotracheal suctioning every hour.

C If the patient with a brain injury is very agitated, benzodiazepines are the most commonly used sedatives and do not affect cerebral blood flow or ICP. The HOB should be elevated 30 degrees. Suctioning should be done a limited basis, due to increasing the pressure in the cranium. The Valsalva maneuver is to be avoided. This also causes increased ICP A patient with a C5 spinal cord injury is tetraplegic. After being moved out of the ICU, the patient complains of a severe throbbing headache.What should the nurse do first?

• Check the patients indwelling urinary catheter for kinks to ensure patency.
• Lower the HOB to improve perfusion.
• Administer analgesia.
• Reassure the patient that headaches are expected after spinal cord injuries.

A A severe throbbing headache is a common symptom of autonomic dysreflexia, which occurs after injuries to the spinal cord above T6. The syndrome is usually brought on by sympathetic stimulation, such as bowel and bladder distention. Lowering the HOB can increase ICP.

A patient is admitted to the neurologic ICU with a spinal cord injury. When assessing the patient the nurse notes there is a sudden depression of reflex activity in the spinal cord below the level of injury. What should the nurse suspect?

• Epidural hemorrhage
• Hypertensive emergency
• Spinal shock
• Hypovolemia

C In spinal shock, the reflexes are absent, BP and heart rate fall, and respiratory failure can occur. Hypovolemia, hemorrhage, and hypertension do not cause this sudden change in neurologic function A patient with a T2 injury is in spinal shock. The nurse will expect to observe what assessment finding?

• Absence of reflexes along with flaccid extremities
• Positive Babinskis reflex along with spastic extremities
• Hyperreflexia along with spastic extremities
• Spasticity of all four extremities

A During the period immediately following a spinal cord injury, spinal shock occurs. In spinal shock, all reflexes are absent and the extremities are flaccid. When spinal shock subsides, the patient demonstrates a positive Babinskis reflex, hyperreflexia, and spasticity of all four extremities.A nurse is reviewing the trend of a patients scores on the Glasgow Coma Scale (GCS). This allows the nurse to gauge what aspect of the patients status?

• Reflex activity
• Level of consciousness
• Cognitive ability
• Sensory involvement

B The Glasgow Coma Scale (GCS) examines three responses related to LOC: eye opening, best verbal response, and best motor response.The nurse is caring for a patient who is rapidly progressing toward brain death. The nurse should be aware of what cardinal signs of brain death?Select all that apply.

• Absence of pain response
• Apnea
• Coma
• Absence of brain stem reflexes
• Absence of deep tendon reflexes

B,C,D The three cardinal signs of brain death upon clinical examination are coma, the absence of brain stem reflexes, and apnea