Exam 73: Management of Clients with Neurologic Trauma

When the nurse assesses brain tissue extruding through an unstable skull fracture, it is documented as which type of herniation syndrome?

The nurse explains to the family of a client with a traumatic brain injury (TBI) that research has shown quality of life can be enhanced by rehabilitation in which of the following areas? (Select all that apply)

A priority nursing intervention for a client in the emergency department with a suspected spinal cord injury is to

The nurse explains that irreversible brain tissue damage is probable when the blood flow to the brain is reduced by

When the client who has an incomplete lesion of the spinal cord complains of more weakness in his upper extremities than in his lower extremities, the nurse recognizes these manifestations to be consistent with

When the client who has been in flaccid spinal shock dorsiflexes the great toe and fans the other toes when the sole of his foot is stroked, the nurse is

A client with a spinal cord lesion experiences a sudden, painful spasm of his lower limbs. The priority action by the nurse is to

When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse would interpret this as

A male client with a spinal cord injury at the level of C5 is despondent relative to the termination of sexual relations because of his injury. The nurse counsels that erections are possible with

The nurse explains to a family that immediate medical-surgical stabilization after a severe cervical injury would include

The client with a spinal cord injury asks the nurse why he must stand on the tilt table every day. The nurse should base the answer on the fact that weight-bearing

When a client with upper motor neuron damage following a spinal cord injury is experiencing a neurogenic bowel, the nurse would alter the plan of care to include

The nurse encourages the client who has sustained a C5 complete spinal cord injury that he should anticipate that he will be able to

An elderly client who was found unresponsive at home now opens his eyes when spoken to and answers simple questions when asked; and left alone usually sleeps. The nurse would document this information in the Glasgow Coma Scale using the categories of

The nurse teaches a group of high school students that the best way to avoid a spinal cord injury is to avoid

To assess motor response, the nurse performing a neurologic assessment on a client in a coma would ask the client to

The nurse working with an ICP monitor institutes which actions? The nurse (Select all that apply)

While caring for a spinal cord-injured client, the nurse notes that he is flushed and sweating profusely, complaining of headache and nausea, and that his blood pressure is elevated with a slow pulse rate. The priority intervention should be to

The nurse is assessing a client for manifestations of recovery from spinal shock. Which of the following assessment findings would indicate that spinal shock is resolving?

Following a spinal cord injury, assessment revealed left-side motor paralysis with loss of vibratory and position sense, and right-side loss of pain and temperature sensation. The nurse recognizes the spinal cord syndrome of