ATI LPN
Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition
Chapter 39 : Caring for Clients With Head and Spinal Cord Trauma Questions
Question 1 of 5
The nurse and physician are viewing a brain scan, which indicates bleeding at the point of impact to the skull and edema on the opposite side. The client is sleeping but can be aroused. The client has no memory of the accident. The nurse provides all details to the next shift and is most accurate to report which type of injury?
Correct Answer: D
Rationale: The nurse most accurately reports a contrecoup injury because the client has this type of dual brain injury. The client has experienced not only a direct strike to the brain but the brain ricochets in the skull to the opposite side causing damage and inflammation at that location as well. The client experienced a head injury, which is a general term. The injury is a contusion because it is more serious than a concussion and leads to structural injury to the brain. It is inaccurate to report a coup injury because this reveals injury to the brain itself from a direct strike to the head.
Question 2 of 5
The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care?
Correct Answer: C
Rationale: The client who has history of playing many years of a physical sport such as soccer and use the head to redirect the ball may have had years of injury to the brain. When concussions occur repetitively, even though they may have not shown injury at that time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy, which can produce neurodegeneration, will need specialized care. The client who has a history of seizures may have no brain injury. The client who was in a previous accident may have had injury, but it is not of a repetitive nature. The client with a father who has Parkinson's disease will have regular follow-up care.
Question 3 of 5
A client has sustained a head injury and is unconscious in the emergency room. A family member of the client arrives and is providing details of the client's medical history. Which information is of most concern to the nurse?
Correct Answer: B
Rationale: The nurse is most concerned that the client is prescribed warfarin (Coumadin) because this is a blood thinner. Due to the action of the medication, the client is at a high risk for intracranial bleeding. The cardiovascular system will be assessed, but that is not the area of greatest concern at this time. The nurse will care for the HIV positive client using standard precautions. A history of concussions may indicate past brain damage, but the potential for active bleeding is the highest concern.
Question 4 of 5
A nurse is reviewing a CT scan of the brain, which shows that the client has arterial bleeding with blood accumulation above the dura. Which of the following facts of the disease progression is essential to guide the nursing management of client care?
Correct Answer: B
Rationale: The nurse identifies that the CT scan suggests an epidural hematoma. A key component in planning care is the understanding that rapid neurologic deterioration occurs. Symptoms evolve quickly. A crash cart may be kept nearby, but this is not the key information. An intracerebral hematoma is bleeding within the brain, which is a different area of bleeding.
Question 5 of 5
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
Correct Answer: B
Rationale: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9?°F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.