Management of Patients with Neurologic Trauma

ManagementofPatientswithNeurologicTrauma  1. 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? A) Epistaxis B) Periorbitaledema C) Bruisingoverthemastoid D) Unilateralfacialnumbness Ans: C Feedback: Anareaofecchymosis(bruising)maybeseenoverthemastoid(Battlessign)inabasilarskullfracture. Numbness,edema,andepistaxisarenotdirectlyassociatedwithabasilarskullfracture. 2. 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? A) Riskforimpairedskinintegrity B) Riskforinjury C) Riskforautonomicdysreflexia D) Riskforsuffocation Ans: B Feedback: 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. 3. Anurseiscaringforacriticallyillpatientwithautonomicdysreflexia.Whatclinicalmanifestations wouldthenurseexpectinthispatient? A) Respiratorydistressandprojectilevomiting B) Bradycardiaandhypertension C) Tachycardiaandagitation D) Third-spacingandhyperthermia Ans: B Feedback: 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. 4. 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? A) Hyperthermia B) Tachycardia C) Hypertension D) Bradypnea Ans: A Feedback: 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. 5. 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? A) Insertionofanintracranialmonitoringdevice B) Treatmentwithantihypertensives C) Emergencycraniotomy D) Administrationofanticoagulanttherapy Ans: C Feedback: 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.Antihypertensivemedicationswouldnotbea priority.Anticoagulanttherapyshouldnotbeorderedforapatientwhohasacranialbleed.Thiscould furtherincreasebleedingactivity.Insertionofanintracranialmonitoringdevicemaybedoneduringthe surgery,butisnotpriorityforthispatient. 6. 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? A) Preparetotransfusepackedredbloodcells. B) PrepareforinterventionstoincreasethepatientsBP. C) PlacethepatientintheTrendelenbergposition. D) Prepareanicebathtolowercorebodytemperature. Ans: B Feedback: 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. 7. 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? A) Sports-relatedinjuries B) Actsofviolence C) Injuriesduetoafall D) Motorvehicleaccidents Ans: D Feedback: ThemostcommoncausesofSCIsaremotorvehiclecrashes(46%),falls(22%),violence(16%),and sports(12%). 8. 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? A) Placingthepatientonafluidrestrictionasordered B) Applyingthigh-highelasticstockings C) Administeringanantifibrinolyicagent D) Assistingthepatientwithpassiverangeofmotion(PROM)exercises Ans: B Feedback: 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.Thepatientshouldnotbe placedonfluidrestrictionbecauseadehydratedstatewillincreasetheriskofclottingthroughoutthe body.Antifibrinolyticagentscausethebloodtoclot,whichisabsolutelycontraindicatedinthis situation.PROMexercisesarenotaneffectiveprotectionagainstthedevelopmentofDVT. 9. ParamedicshavebroughtanintubatedpatienttotheRDfollowingaheadinjuryduetoaccelerationdecelerationmotorvehicleaccident.IncreasedICPissuspected.Appropriatenursinginterventions wouldincludewhichofthefollowing? A) Keeptheheadofthebed(HOB)flatatalltimes. B) TeachthepatienttoperformtheValsalvamaneuver. C) AdministerbenzodiazepinesonaPRNbasis. D) Performendotrachealsuctioningeveryhour. Ans: C Feedback: 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. 10. Apatientwhohassustainedanondepressedskullfractureisadmittedtotheacutemedicalunit.Nursing careshouldincludewhichofthefollowing? A) Preparationforemergencycraniotomy B) Watchfulwaitingandclosemonitoring C) Administrationofinotropicdrugs D) Fluidresuscitation Ans: B Feedback: Nondepressedskullfracturesgenerallydonotrequiresurgicaltreatment;however,closeobservationof thepatientisessential.Acraniotomywouldnotlikelybeneededifthefractureisnondepressed.Evenif treatmentiswarranted,itisunlikelytoincludeinotropesorfluidresuscitation. 11. Apatientwhosufferedaspinalcordinjuryisexperiencinganexaggeratedautonomicresponse.What aspectofthepatientscurrenthealthstatusismostlikelytohaveprecipitatedthisevent? A) Thepatientreceivedabloodtransfusion. B) Thepatientsanalgesiaregimenwasrecentchanged. C) Thepatientwasnotrepositionedduringthenightshift. D) Thepatientsurinarycatheterbecameoccluded. Ans: D Feedback: Adistendedbladderisthemostcommoncauseofautonomicdysreflexia.Infrequentpositioningisaless likelycause,althoughpressureulcersortactilestimulationcancauseit.Changesinmediationsorblood transfusionsareunlikelycauses. 12. ApatientisadmittedtotheneurologicICUwithaspinalcordinjury.Inwritingthepatientscareplan, thenursespecifiesthatcontracturescanbestbepreventedbywhataction? A) Repositioningthepatientevery2hours B) Initiatingrange-of-motionexercises(ROM)assoonasthepatientinitiates C) Initiating(ROM)exercisesassoonaspossibleaftertheinjury D) PerformingROMexercisesonceaday Ans: C Feedback: PassiveROMexercisesshouldbeimplementedassoonaspossibleafterinjury.Itwouldbe inappropriatetowaitforthepatienttofirstinitiateexercises.Toes,metatarsals,ankles,knees,andhips shouldbeputthroughafullROMatleastfour,andideallyfive,timesdaily.Repositioningalonewill notpreventcontractures. 13. Apatientwithaheadinjuryhasbeenincreasinglyagitatedandthenursehasconsequentlyidentifieda riskforinjury.Whatisthenursesbestinterventionforpreventinginjury? A) Restrainthepatientasordered. B) AdministeropioidsPRNasordered. C) Arrangeforfriendsandfamilymemberstositwiththepatient. D) Padthesiderailsofthepatientsbed. Ans: D Feedback: Toprotectthepatientfromself-injury,thenurseusespaddedsiderails.Thenurseshouldavoid restraints,becausestrainingagainstthemcanincreaseICPorcauseotherinjury.Narcoticsusedto controlrestlesspatientsshouldbeavoidedbecausethesemedicationscandepressrespiration,constrict thepupils,andalterthepatientsresponsiveness.Visitorsshouldbelimitedifthepatientisagitated. 14. 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? A) Checkthepatientsindwellingurinarycatheterforkinkstoensurepatency. B) LowertheHOBtoimproveperfusion. C) Administeranalgesia. D) Reassurethepatientthatheadachesareexpectedafterspinalcordinjuries. Ans: A Feedback: 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.Beforeadministering analgesia,thenurseshouldcheckthepatientscatheter,recordvitalsigns,andperformanabdominal assessment.Aseverethrobbingheadacheisadangeroussymptominthispatientandisnotexpected. 15. 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? A) Epiduralhemorrhage B) Hypertensiveemergency C) Spinalshock D) Hypovolemia Ans: C Feedback: 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. 16. Anelderlywomanfoundwithaheadinjuryonthefloorofherhomeissubsequentlyadmittedtothe neurologicICU.Whatisthebestrationaleforthefollowingphysicianorders:elevatetheHOB;keepthe headinneutralalignmentwithnoneckflexionorheadrotation;avoidsharphipflexion? A) Todecreasecerebralarterialpressure B) Toavoidimpedingvenousoutflow C) Topreventflexioncontractures D) Topreventaspirationofstomachcontents Ans: B Feedback: Anyactivityorpositionthatimpedesvenousoutflowfromtheheadmaycontributetoincreasedvolume insidetheskullandpossiblyincreaseICP.Cerebralarterialpressurewillbeaffectedbythebalance betweenoxygenandcarbondioxide.Flexioncontracturesarenotapriorityatthistime.Stomach contentscouldstillbeaspiratedinthisposition. 17. ApatientwithaT2injuryisinspinalshock.Thenursewillexpecttoobservewhatassessmentfinding? A) Absenceofreflexesalongwithflaccidextremities B) PositiveBabinskisreflexalongwithspasticextremities C) Hyperreflexiaalongwithspasticextremities D) Spasticityofallfourextremities Ans: A Feedback: 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. 18. 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? A) Reflexactivity B) Levelofconsciousness C) Cognitiveability D) Sensoryinvolvement Ans: B Feedback: TheGlasgowComaScale(GCS)examinesthreeresponsesrelatedtoLOC:eyeopening,bestverbal response,andbestmotorresponse. 19. 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. A) Absenceofpainresponse B) Apnea C) Coma D) Absenceofbrainstemreflexes E) Absenceofdeeptendonreflexes Ans: B,C,D Feedback: Thethreecardinalsignsofbraindeathuponclinicalexaminationarecoma,theabsenceofbrainstem reflexes,andapnea.Absencesofpainresponseanddeeptendonreflexesarenotnecessarilyindicativeof braindeath. 20. Followingaspinalcordinjuryapatientisplacedinhalotraction.Whileperformingpinsitecare,the nursenotesthatoneofthetractionpinshasbecomedetached.Thenursewouldbecorrectin implementingwhatprioritynursingaction? A) Completethepinsitecaretodecreaseriskofinfection. B) Notifytheneurosurgeonoftheoccurrence. C) Stabilizetheheadinalateralposition. D) Reattachthepintopreventfurtherheadtrauma. Ans: B Feedback: Ifoneofthepinsbecamedetached,theheadisstabilizedinneutralpositionbyonepersonwhileanother notifiestheneurosurgeon.Reattachingthepinasanursinginterventionwouldnotbedoneduetoriskof increasedinjury.Pinsitecarewouldnotbeapriorityinthisinstance.Preventionofneurologicinjuryis thepriority. 21. TheEDisnotifiedthata6-year-oldisintransitwithasuspectedbraininjuryafterbeingstruckbyacar. Thechildisunresponsiveatthistime,butvitalsignsarewithinacceptablelimits.Whatwillbethe primarygoalofinitialtherapy? A) Promotingadequatecirculation B) TreatingthechildsincreasedICP C) Assessingsecondarybraininjury D) Preservingbrainhomeostasis Ans: D Feedback: Alltherapyisdirectedtowardpreservingbrainhomeostasisandpreventingsecondarybraininjury, whichisinjurytothebrainthatoccursaftertheoriginaltraumaticevent.Thescenariodoesnotindicate thechildhasincreasedICPorasecondarybraininjuryatthispoint.Promotingcirculationislikely secondarytothebroadergoalofpreservingbrainhomeostasis. 22. ApatientisadmittedtotheneurologicICUwithasuspecteddiffuseaxonalinjury.Whatwouldbethe primaryneuroimagingdiagnostictoolusedonthispatienttoevaluatethebrainstructure? A) MRI B) PETscan C) X-ray D) Ultrasound Ans: A Feedback: CTandMRIscans,theprimaryneuroimagingdiagnostictools,areusefulinevaluatingthebrain structure.Ultrasoundwouldnotshowthebrainnorwouldanx-ray.APETscanshowsbrainfunction, notbrainstructure. 23. A13-year-oldwasbroughttotheED,unconscious,afterbeinghitintheheadbyabaseball.Whenthe childregainsconsciousness,5hoursafterbeingadmitted,hecannotrememberthetraumaticevent.MRI showsnostructuralsignofinjury.Whatinjurywouldthenursesuspectthepatienthas? A) Diffuseaxonalinjury B) Grade1concussionwithfrontallobeinvolvement C) Contusion