Trauma/SCI/TBI/ICP NCLEX Questions

Trauma/SCI/TBI/ICP NCLEX Questions Leave the first rating Students also studied Terms in this set (9) Northern Arizona UniversityNUR 375 Save Spinal Cord Injury NCLEX Questions...Teacher 53 terms julia11213Preview ATI comprehensive predictor STUDY...198 terms h_trtPreview Acute Kidney Injury Nclex Question...18 terms yi_yan7Preview Adult H 20 terms sup Which of the following signs and symptoms of increased ICP after head trauma would appear first?a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure c.) Restlessness and confusion

Rationale:

The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising?a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure.b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure.d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure.b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

Rationale:

A change in vital signs may be a late sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respirations. Respiratory irregularities also may arise.

A nurse is planning care for a child with acute bacterial meningitis. Based on the mode of transmission of this infection, which of the following would be included in the plan of care?a.) No precautions are required as long as antibiotics have been started b.) Maintain enteric precautions c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics d.) Maintain neutropenic precautions c.) Maintain respiratory isolation precautions for at least 24 hours after the initiation of antibiotics

Rationale:

A major priority of nursing care for a child suspected of having meningitis is to administer the prescribed antibiotic as soon as it is ordered. The child is also placed on respiratory isolation for at least 24 hours while culture results are obtained and the antibiotic is having an effect.The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of

surgery if the client exhibits:

a.) A positive Brudzinski's sign b.) A negative Kernig's sign c.) Absence of nuchal rigidity d.) A Glascow Coma Scale score of 15 a.) A positive Brudzinski's sign

Rationale:

Signs of meningeal irritation compatible with meningitis include nuchal rigidity, positive Brudzinski's sign, and positive Kernig's sign. Nuchal rigidity is characterized by a stiff neck and soreness, which is especially noticeable when the neck is fixed. Kernig's sign is positive when the client feels pain and spasm of the hamstring muscles when the knee and thigh are extended from a flexed-right angle position. Brudzinski's sign is positive when the client flexes the hips and knees in response to the nurse gently flexing the head and neck onto the chest. A Glascow Coma Scale of 15 is a perfect score and indicates the client is awake and alert with no neurological deficits.For a male client with suspected increased intracranial

pressure (ICP), a most appropriate respiratory goal is to:

a.) Prevent respiratory alkalosis.b.) Lower arterial pH.c.) Promote carbon dioxide elimination.d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg c.) Promote carbon dioxide elimination.

Rationale:

The goal in treatment is to prevent acidemia by eliminating carbon dioxide.A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best

fluid replacement for this patient would be:

a.) Normal saline.b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS a.) Normal saline.

Rationale:

A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water.#2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema.#3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

The nurse is caring for a client with a closed head injury.Which of the following would contribute to intracrainal hypertension?a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnent a.) hypoventilation

Rationale:

Hypoventilation leads to vasodilation and increased intracranial pressure.A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space a.) Laceration of the middle meningeal artery

Rationale:

Epidural hematoma or extradural hematoma is usually caused by laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?a.) Absence of pain sensation in chest b.) Spasticity c.) Spontaneous respirations d.) Urinary continence b.) Spasticity

Rationale:

Spasticity, the return of reflexes, is a sign of resolving shock. Spinal or neurogenic shock is characterized by hypotension, bradycardia, dry skin, flaccid paralysis, or the absence of reflexes below the level of injury. The absence of pain sensation in the chest doesn't apply to spinal shock. Spinal shock descends from the injury, and respiratory difficulties occur at C4 and above.