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 is caring for a client with impaired physical mobility who has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in this client?
Correct Answer: C
Rationale: The nurse should keep the client hydrated. Adequate hydration reduces the potential for the formation of thrombi and renal calculi. A well-balanced diet provides nutrients and elements necessary for energy and to sustain cellular growth and repair. Positioning the client helps avoid joint contractures and foot drop. Active and passive exercise maintains joint flexibility and reduces muscle atrophy and atony.
Question 2 of 5
A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be?
Correct Answer: D
Rationale: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. The other options are incorrect because they give incorrect information to the mother.
Question 3 of 5
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
Correct Answer: D
Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage.
Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
Question 4 of 5
The nurse is caring for a client who has had intracranial surgery and is being discharged home. What instructions would the nurse give the client besides instructions on the medication?
Correct Answer: D
Rationale: In addition, the nurse must provide the following verbal and written instructions: Watch for signs of intracranial bleeding and infection (expect swelling around the eye and below the incision). Expect sensory changes such as hearing a 'clicking' sound around the bone flap, which will disappear as healing takes place. Understand that headaches also are common, but notify the surgeon if a mild analgesic such as acetaminophen fails to relieve them. Care for the surgical site as directed by the physician. Some recommendations include keeping the incision clean, avoiding scrubbing the incision, securing remaining hair away from the incision, resuming shampooing the hair when the staples or sutures are removed, and wearing a hat when outside to avoid sunburn until hair growth resumes. Maintain safety precautions at home, including ambulating only with assistance and ensuring well-lit and clutter-free rooms. Do not drive until the risk of seizures has been eliminated. Engage in exercises that promote strength and endurance. Use techniques to ensure bowel and bladder elimination. Follow feeding and/or nutritional suggestions. Keep follow-up appointments for measuring anticonvulsant blood levels, electroencephalograms, and continued medical care and evaluation. This information is usually given to the client on a take-home instruction sheet.
Question 5 of 5
The nurse is caring for a client who was discovered unconscious after falling off a ladder. The client is diagnosed with a concussion. All testing is normal, and discharge instructions are compiled. Which instructions have been compiled for the spouse?
Correct Answer: B
Rationale: All of the options are typical for a client being discharged with a concussion. The instruction that is emphasized is to observe for any signs of behavior changes, which may indicate an increase in the client's intracranial pressure. A concussion results in diffuse or microscopic injury to the brain with symptoms that may evolve.