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HEAD INJURY

1. Which of the following is not one of the factors that determine the type of TBI?
A. Genetic variations B. Nature of the external force
C. Motivation of the patient D. Strength of the force
2. What type of injury most often results from blunt force trauma?
A. Coup or coup-contra-coup B. Epidural hematoma
C. Penetrating injury D. Subarachnoid hemorrhage
3. A penetrating brain injury is defined by
A. A depressed skull fracture. B. Foreign matter disrupting the dura.
C. Increased intracranial pressure. D. A linear skull fracture.
4. What is the most common mechanism of brain injury on the Iraq and Afghanistan
battlefields?
A. Blast/explosions B. Falls
C. Gunshot wounds to the head or neck D. Motor vehicle accidents
5. What causes secondary blast injury from an explosion?
A. Direct exposure to the overpressurization wave of the explosion
B. Inhalation of gases or other toxic substances
C. The body is displaced and impacts another object
D. Energized debris or explosive fragments impact the head
6. What is 1 indicator that characterizes moderate TBI?
A. Glasgow Coma Scale (GCS) score of 13 to 15
B. Loss of consciousness/alteration of consciousness between 1 and 24 hours
C. Posttraumatic amnesia >7 days
D. GCS score of 3 to 8
E. All of the above
7. If the patient has a mild TBI with positive radiologic findings, the patient has a
A. Moderate TBI. B. Prognosis of a severe TBI.
C. Complicated mild TBI. D. Simple severe TBI.
8. TBI is classified by
A. Functional status at 12 months. B. Progress more than 6 months.
C. Severity of the initial injury. D. Rate of recovery.
9. What type of care is included in “buddy aid”?
A. Cover fire and evacuation to a safe zone B. Documentation of mental status
C. Prevention of hypoxia and hypothermia D. Triagé
10. What type of care is provided at the Combat Support Hospital?
A. Aggressive intracranial pressure therapy B. Emergent neurosurgical care
C. Field management of a TBI D. Long-term intensive care
11. At Landstuhl Regional Medical Center, patients are treated and evacuated stateside,
usually within
A. 36 hours. B. 48 hours. C. 72 hours. D. 96 hours.
12. What special provision must be made during air transfer of a patient with a comorbid
pulmonary injury?
A. Nonpressurized cabin B. Presence of a physician on board
C. Shorter flight time D. Lower flight altitude
13. The GCS is less strongly associated with
A. Acute morbidity. B. Long-term functional outcome.
C. Acute mortality. D. Neurologic status.
14. According to the Rancho Los Amigos Scale, Level VIII is reported as
A. Confused—appropriate. B. Localized response.
C. No response. D. Purposeful and appropriate response.
15. During rehabilitation at the polytrauma center, who coordinates and directs the
rehabilitation team?
A. Case manager B. Neuropsychologist
C. Physiatrist D. Physical therapist
16. What is one of the ways that the Department of Veterans Affairs and Department of
Defense communicate and coordinate care?
A. Secure records transfers B. Teleconferencing
C. Through Department of Veterans Affairs social workers D. Videoconferencing
17. According to I. Schwartz et al (2008), how many of the “terror victims” who suffer
more severe TBI return to their previous work or school?
A. 14% B. 22% C. 38% D. 47%
18. What is one of the biomarkers that shows promise in the evaluation of TBI?
A. Creatine kinase B. Nitrotyrosine
C. Rubidium chloride D. Troponin-I
( https://www.proprofs.com/quiz-school/story.php?title=bonus-quiz-traumatic-brain-injury )
19. A nurse is caring for a client who was recently admitted to the emergency department
following a head-on motor vehicle crash. The client is unresponsive, has spontaneous
respirations of 22/min, and a laceration on his forehead that is bleeding. Which of the
following is the priority nursing action at this time?
A. Keep neck stabilized
B. Insert NG tube
C Monitor pulse and blood pressure frequently
D. Establish IV access and start fluid replacement
20. A nurse is caring for a client who has just been admitted following surgical evacuation
of a subdural hematoma. Which of the following is the priority assessment?
A. Glasgow coma scale B. Cranial nerve function
C. Oxygen saturation D. Pupillary response
21. A nurse is caring for a client who has a closed-head injury with ICP readings range
from 16 to 22 mmHg. Which of the following actions should the nurse take to decrease the
potential for raising the client's ICP? (Select all that apply)
A. Suction the endotracheal tube B. Hyperventilate the client
C. Elevate the client's head on two pillows D. Administer a stool softener
E. Keep the client well hydrated
22. A nurse in the critical care unit is completing an admission assessment of a client who
has a gunshot wound to the head. Which of the following assessment findings are indicative
of increased ICP? (Select all that apply)
A. Headache B. Dilated pupils C. Tachycardia D. Decorticate posturing E. Hypotension
23. A nurse is caring for a client who has increased ICP and a new prescription for
mannitol (Osmitrol). For which of the following adverse effects should the nurse monitor?
A. Hyperglycemia B. Hyponatremia C. Hypervolemia D. Oliguria
(https://quizlet.com/131206699/ati-med-surge-ch-14-head-injury-flash-cards/ )
23. After a nursing assessment, the nurse documents that a client is confused. Which
behaviors did the nurse assess to determine this client's level of consciousness?
(Select all that apply.)
a Does not remember home address
b Does not know why hospitalization is required
c Responds to verbal stimuli but quickly falls back asleep
d Uses inappropriate words to describe situations
e Moans in response to painful stimuli
24. The nurse is caring for a client with a traumatic brain injury. Which assessment finding
indicates that the client would benefit from a histamine H2 antagonist?
a Stool guaiac positive b Blood pressure increasing to 168/88 mmHg
c Body temperature of 101degrees°F d Restlessness and easily agitated
25. The nurse assesses a respiratory rate of 8 breaths per minute in a client with a
traumatic brain injury. Shortly thereafter the client begins hiccupping. Which part of the
brain should the nurse suspect is being affected in this client?
a Cerebellum b Occipital lobe c Brainstem d Thalamus
26. The nurse is preparing to conduct a neurologic assessment interview with a client.
Which general questions should the nurse use when conducting this assessment?
(Select all that apply.)
a "Are you experiencing any pain?"
b "How many fingers am I holding up at this time?"
c "Do you have a history of seizures or fainting?"
d "Do you have any problems with balance or coordination?"
e "Are you having any problems with your memory?"
27. A client with a minor head injury has a Glasgow Coma score of 15. What does this
score indicate to the nurse?
(Select all that apply.)
a Client is oriented to person, place, and time. b Client withdraws to pain.
c Client withdraws to touch. d Client uses appropriate words and phrases.
e Client spontaneously opens the eyes.
28. A client with a traumatic brain injury is diagnosed as being brain dead. Which
assessment finding supports this diagnosis?
a Aware of environment but unable to communicate b Complete unawareness of self
c Neck extended and the jaw is clenched d Absence of spontaneous respirations
29. The nurse is concerned that a client recovering from a stroke may have parietal lobe
damage. Which observations made by the nurse support this concern?
(Select all that apply.)
a Client did not respond when foot was caught in the side rail.
b Client did not respond when hot coffee was spilled on the hand.
c Client is unable to move the left hand independently.
d Client is unable to speak.
e Client did not react when the trash can in the room caught on fire.
30. Which phrase describes a reflex?
a Rapid, involuntary, predictable motor response to a stimulus
b Relay center for all information coming into the brain
c Brain matter responsible for muscle movement and balance
d Control center that regulates heart rate and blood pressure
31. How does increased intracranial pressure affect brain tissue?
a Transmits sensory and motor impulses to the cerebrum for interpretation
b Alters electrical discharges in the brain to cause involuntary movement
c Removes fluid from interstitial spaces to reduce excess body fluid
d Causes an oxygen deficit that leads to changes in personality, memory, and judgment
32. What should the nurse do to reduce the risk of traumatic brain injury in people over
the age of 65?
a Conduct a home safety assessment b Restrict movement with chemical restraints
c Suggest a reduction in activity d Prevent participation in contact sports
33. Why should the neurological assessment of an older client be modified?
a Easily fatigued b Less efficient long-term memory
c Increased reaction to stimuli d Shorter attention span
34. What does the Glasgow Coma Scale assess?
(Select all that apply.)
a Verbal response b Corneal reflex c Cerebellar function d Motor response e Eye opening
35. Which are independent nursing interventions for an alteration in intracranial
regulation?
(Select all that apply.)
a Provide antianxiety medication through intravenous site
b Reduce the lights in the room c Shine a light into the client's eyes
d Raise the head of the bed e Insert an indwelling urinary catheter
36. The nurse is drawing an arterial blood sample from Jamal Lemmington, a 22-year-old
male diagnosed with a traumatic brain injury. What should the nurse explain to Jamal's
father about the purpose of this blood sample?
a Estimates the length of time it will take for the client to resume consciousness
b Measures the amount of carbon dioxide in the blood to predict the presence of increased
intracranial pressure
c Determines the response of medications to remove excess fluid from the brain tissue and
reduce swelling
d Predicts the number and depth of respirations that the client will have during one minute
37. The nurse is preparing a plan of care for Jimmy Williams, a 30-year-old client
recovering from a head injury. Which collaborative action should the nurse perform to
help reduce cerebral edema?
a Regulate the infusion of a proton pump inhibitor
b Apply a cooling blanket
c Administer ethacrynic acid (Edecrin) as prescribed
d Administer antihypertensive medication as prescribed
38. During a physical examination, the nurse assesses the reflexes of an older client. Which
reflex would require notification to the healthcare provider?
a Gag b Achilles c Babinski d Corneal
39. A client is admitted with an L4-L5 injury. Which diagnostic tests should the nurse
anticipate would be prescribed for this client?
(Select all that apply.)
a MRI b Myelogram c Nerve conduction studies d Brain echogram
e Cerebral angiogram
40. The nurse instructs the parents of school-age children on ways to prevent head injuries.
Which statement made by a participant indicates that additional teaching is required?
a "I need to get my son a helmet to wear when ice skating."
b "My daughter needs to wear a helmet when riding the bicycle."
c "My son should wear protective shoulder and knee pads when playing football."
d "Even though he won't like it, I'll make sure my son wears a helmet when skateboarding."
41. A client with a traumatic brain injury is intubated and placed on mechanical
ventilation. What should the nurse use to evaluate the effectiveness of these respiratory
interventions?
a Cranial nerve function b Motor and sensory function
c Arterial blood gas results d Glasgow Coma score
42. A client recovering from a stroke is unable to swallow and has an absent gag reflex.
Which cranial nerve should the nurse suspect is affected in this client?
a Spinal accessory b Glossopharyngeal c Hypoglossal d Trigeminal
43. A client experiences fractures of the left leg and a traumatic brain injury in a dirt bike
accident and is admitted to the intensive care unit. Which assessment finding indicates
increased intracranial pressure (IICP)?
a Nausea b Irritability c Hypotension d Oliguria
44. A nurse in the intensive care unit is providing care for a client with increased
intracranial pressure (IICP). The nurse monitors the client for which manifestations of
IICP?
(Select all that apply.)
a Decreased level of consciousness b Decreased blood pressure
c Projectile vomiting d Increased heart rate e Dilated pupils
45. A nurse in the emergency department is providing care for a client who has increased
intracranial pressure (IICP) from a traumatic brain injury from a motor vehicle crash.
The nurse anticipates orders for which diagnostic tests in the care of this client?
(Select all that apply.)
a ABGs b Cardiac monitoring c CT of the head d Electromyogram
e Intracranial pressure monitor
46. The client has an increase in intracranial pressure caused by an increase in capillary
permeability. The nurse should recognize this as which type of cerebral edema?
a Hormonal b Vasogenic c Bacterial d Cytotoxic
47. What is the most frequent cause of increased intracranial pressure (IICP)?
a Hemorrhage b Tumors c Abscesses d Cerebral edema
48. What is the intended action of mannitol in the treatment of a client with increased
intracranial pressure?
a To enhance renal excretion of retained protein
b To create a sodium and potassium balance
c To draw fluid from the brain tissue
d To prevent tiny stress hemorrhages in the brain
49. In addition to measuring intracranial pressure, what is the purpose of inserting an
intraventricular catheter for a client with alteration of intracranial pressure?
a To drain cerebrospinal fluid
b To administer medication to reduce cerebral inflammation
c To shunt excess cerebrospinal fluid around an obstruction in the ventricular system
d To resect excess brain tissue
50. Which assessments should the nurse include when examining a client with an alteration
in intracranial pressure?
(Select all that apply.)
a Level of consciousness b Motor status and strength
c Vital signs d Fluid intake for the past 24 hours
e Pupillary responses to light
51. A nurse is providing care for a client with a traumatic head injury. The nurse should
monitor the client for which manifestations consistent with increased intracranial
pressure?
(Select all that apply.)
a Headache b Blurred vision c Double vision d Increased heart rate e Drowsiness
52. The client is being treated for increased intracranial pressure (IICP). Which of these
manifestations should indicate to the nurse that the outcomes are being met for this client?
(Select all that apply.)
a Blood pressure = 118/76 b No redness or drainage at site of intraventricular catheter
c Verbalizes need to increase stimuli d Lethargic
e Intracranial pressure = 14 mmHg
53. The spouse of a client who has increased intracranial pressure (IICP) asks the nurse
what is happening in her husband's brain. Based on the pathophysiology, which is the best
response by the nurse?
a "Something in the brain, its blood, or surrounding fluid is off balance and has caused an
increased pressure."
b "The blood flow to the brain has increased and is causing an increased pressure."
c "There must be a tumor causing the increase in pressure we are seeing."
d "Your husband's low blood pressure is causing the brain to have too much fluid in it.
54. The nurse is using the glascow coma scale to assess the clients motor response. The
nurse places pressure at the base of the clients fingernail for 20 seconds, The clients only
response is withdrawal of his hand. The nurse interprets the clients response as:
a. a score of 6 because he follows command b. a score of 5 because he localizes pain
c. a score of 4 because he uses flexion d. a score of 3 because he uses extension
55. The nurse is caring for a client with a closed head injury. A late sign of ICP is:
a. changes in pupil reactivity and equality b. restlessness and irritability
c. complaints of headache d. irritability
56. a nurse is caring for a client with a head injury who has increased ICP. The physician
plans to reduce cerebral edema by constricting cerebral blood vessels. Which physician
order would serve this purpose?
a. hyperventilation per mechanical ventilation b. insertion of a ventricular shunt
c. furosemide d solu medrol
57. A nurse caring for a client with a head injury would recognize which assessment finding
as most indicative of increased ICP?
a. vomiting b headache c dizziness d papilledema (eyes swell)
58. a client with ICP is receiving Osmitrol (Mannitol) and furosemide (lasix). The nurse
recognizes that these two drugs are given to reverse what effect?
a energy failure b excessive intracellular calcium
c cellular edema d excessive glutamate release
59. When planning care for a client with a posterior fossa craniotomy which action in
contraindicated?
a keeping the client flat on one side b elevating the head of the bed 30 degrees
c log rolling or turning as a unit d keeping the neck in a neutral position
60. A client has signs of ICP, which of the following is an early indicator of deterioration in
the clients condition?
a widening pulse pressure b decrease in pulse rate
c dilated, fixed pupils d decrease LOC
(https://quizlet.com/204517471/intracranial-regulation-icp-flash-cards/ )
SPINAL CORD INJURY

1.A patient with a spinal cord injury at the T1 level complains of a severe headache and an
"anxious feeling." Which is the most appropriate initial reaction by the nurse?
1. Try to calm the patient and make the environment soothing.
2. Assess for a full bladder.
3. Notify the healthcare provider.
4. Prepare the patient for diagnostic radiography.
2. A hospitalized patient with a C7 cord injury begins to yell "I can't feel my legs
anymore." Which is the most appropriate action by the nurse?
1. Remind the patient of her injury and try to comfort her.
2. Call the healthcare provider and get an order for radiologic evaluation.
3. Prepare the patient for surgery, as her condition is worsening.
4. Explain to the patient that this could be a common, temporary problem.
3. The nurse is educating a patient and the family about different types of stabilization
devices. Which statement by the patient indicates that the patient understands the benefit
of using a halo fixation device instead of Gardner-Wells tongs?
1. "I will have less pain if I use the halo device."
2. "The halo device will allow me to get out of bed."
3. "I am less likely to get an infection with the halo device."
4. "The halo device does not have to stay in place as long."
5. The nurse is caring for a patient with increased intracranial pressure (IICP). The nurse
realizes that some nursing actions are contraindicated with IICP. Which nursing action
should be avoided?
1. Reposition the patient every two hours.
2. Position the patient with the head elevated 30 degrees.
3. Suction the airway every two hours per standing orders.
4. Provide continuous oxygen as ordered.
6. A patient with a spinal cord injury (SCI) is admitted to the unit and placed in traction.
Which of the following actions is the nurse responsible for when caring for this patient?
Select all that apply.
1. modifying the traction weights as needed 2. assessing the patient's skin integrity
3. applying the traction upon admission 4. administering pain medication
5. providing passive range of motion
7. A patient has manifestations of autonomic dysreflexia. Which of these assessments would
indicate a possible cause for this condition?
Select all that apply.
1. hypertension 2. kinked catheter tubing 3. respiratory wheezes and stridor
4. diarrhea 5. fecal impaction
8. An unconscious patient receiving emergency care following an automobile crash accident
has a possible spinal cord injury. What guidelines for emergency care will be followed?
Select all that apply.
1. Immobilize the neck using rolled towels or a cervical collar.
2. The patient will be placed in a supine position
3. The patient will be placed on a ventilator.
4. The head of the bed will be elevated.
5. The patient's head will be secured with a belt or tape secured to the stretcher.
9. A patient with a spinal cord injury is recovering from spinal shock. The nurse realizes
that the patient should not develop a full bladder because what emergency condition can
occur if it is not corrected quickly?
1. autonomic dysreflexia 2. autonomic crisis 3. autonomic shutdown 4. autonomic failure
10. Which patient is at highest risk for a spinal cord injury?
1. 18-year-old male with a prior arrest for driving while intoxicated (DWI)
2. 20-year-old female with a history of substance abuse
3. 50-year-old female with osteoporosis
4. 35-year-old male who coaches a soccer team
11. The nurse understands that when the spinal cord is injured, ischemia results and edema
occurs. How should the nurse explain to the patient the reason that the extent of injury
cannot be determined for several days to a week?
1. "Tissue repair does not begin for 72 hours."
2. "The edema extends the level of injury for two cord segments above and below the affected
level."
3. "Neurons need time to regenerate so stating the injury early is not predictive of how the
patient progresses."
4. "Necrosis of gray and white matter does not occur until days after the injury."
12. A patient with a spinal cord injury (SCI) has complete paralysis of the upper
extremities and complete paralysis of the lower part of the body. The nurse should use
which medical term to adequately describe this in documentation?
1. hemiplegia 2. Paresthesia 3. Paraplegia 4. quadriplegia
13. Which of the following nursing actions is appropriate for preventing skin breakdown in
a patient who has recently undergone a laminectomy?
1. Provide the patient with an air mattress.
2. Place pillows under patient to help patient turn.
3. Teach the patient to grasp the side rail to turn.
4. Use the log roll to turn the patient to the side.
14. The patient is admitted with injuries that were sustained in a fall. During the nurse's
first assessment upon admission, the findings are: blood pressure 90/60 (as compared to
136/66 in the emergency department), flaccid paralysis on the right, absent bowel sounds,
zero urine output, and palpation of a distended bladder. These signs are consistent with
which of the following?
1. paralysis 2. spinal shock
3. high cervical injury 4. temporary hypovolemia
15. While caring for the patient with spinal cord injury (SCI), the nurse elevates the head
of the bed, removes compression stockings, and continues to assess vital signs every two to
three minutes while searching for the cause in order to prevent loss of consciousness or
death. By practicing these interventions, the nurse is avoiding the most dangerous
complication of autonomic dysreflexia, which is which of the following?
1. hypoxia 2. Bradycardia 3. elevated blood pressure 4. tachycardia
16. A patient is admitted to the hospital with a CD4 spinal cord injury after a motorcycle
collision. The patient's BP is 83/49, and his pulse is 39 beats/min, and he remains orally
intubated. The nurse identifies this pathophysiologic response as caused by
a. increased vasomotor tone after injury
b. a temporary loss of sensation and flaccid paralysis below the level of injury
c. loss of parasympathetic nervous system innervation resulting in vasoconstriction
d. loss of sympathetic nervous system innervation resulting in peripheral vasodilation
17. A nurse is caring for a client with a spinal cord injury who reports a severe headache
and is sweating profusely. vital signs include BP 220/110, apical heart rate of 54/min.
Which of the following acctions should the nurse take first?
a. notify the provider
b. sit the client upright in bed
c. check the client's urinary catheter for blockage
d. administer antihypertensive medication
18. Following a T2 spinal cord injury, the patient develops paralytic ileus. While this
condition is present, the nurse anticipates that the patient will need
a. IV fluids b. tube feedings
c. parenteral nutrition d. nasogastric suctioning
19. An initial incomplete spinal cord injury often results in complete cord damage because
of
a. edematous compression of the cord above the level of the injury
b. continued trauma to the cord resulting from damage to stabilizing ligaments
c. infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites
d. mecheanical transection of the cord by sharp vertebral bone fragments after the initial injury
20. Two days following a spinal cord injury, a patient asks continually about the extent of
impairment that will result from the injury. The best response by the nurse is,
a. you will have more normal function when spinal shock resolves and the reflex arc returns
b. the extent of your injury cannot be determined until the secondary injury to the cord is
resolved
c. when your condition is more stable, an MRI will be done that can reveal the extent of the cord
damage
d. because long-term rehabilitation can affect the return of tunction, it will be years before we
can tell when the complete effect will be
21. A week following a spinal cord injury at T2, a patient experiences movement in his leg
and tells the nurse he is recovering some function. The nurses' best response to the patient
is,
a. it is really still too soon to know if you will have a return of function
b. the could be a really positive finding. can you show me the movement
c. that's wonderful. we will start exercising your legs more frequently now
d. im sorry, but the movement is only a reflex and does not indicate normal function
22. Urinary function during the acute phase of spinal cord injury is maintained with
a. an indwelling catheter
b. intermittent catheterization
c. insertion of a suprapubic catheter
d. use of incontinent pads to protect the skin
23. A nurse is caring for a client who has a C4 spinal cord injury. which of the following
should the nurse recognize the client as being at the greatest risk for?
a. neurogenic shock b. paralytic ileus
c. stress ulcer d. respiratory compromise
24. During assessment of a patient with a spinal cord injury, the nurse determines that the
patient has a poor cough with diaphragmatic breathing. Based on this finding, the nurses'
first action should be to
a. initiate frequent turning and repositioning
b. use tracheal suctioning to remove secretions
c. assess lung sounds and respiratory rate and depth
d. prepare the patient for endotracheal intubation and mechanical ventilation
25. The healthcare provider has ordered IV dopamine (Intropin) for a patient in the
emergency deparement with a spinal cord injury. The nurse determines that the drug is
having the desired effect when assessment findings include
a. pulse rate of 68 b. respiratory rate of 24
c. BP of 106/82 d. temperature of 96.8
26. A patient is admitted to the emergency department with a spinal cord injury at the level
of T2. Which of the following findings is of most concern to the nurse?
a. SpO2 of 92% b. HR of 42 beats/min
c. BP of 88/60 d. loss of motor and sensory function in arms and legs
27. Without surgical stabilization, immobilization and traction of the patient with a cervical
spinal cord injury most frequently requires the use of
a. kinetic beds b. hard cervical collars
c. skeletal traction with skull tongs d. sternal-occipital-mandibular immobilizer (SOMI) brace
28, A patient with a spinal cord injury has spinal shock. The nurse plans care for the
patient based on the knowledge that
a. rehabilitation measures cannot be initiated until spinal shock has resolved
b. the patient will need continuous monitoring for hypotension, tachycardia, and hypoxemia
c. resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of
the bladder
d. the patient will have complete loss of motor and sensory functions below the level of the
injury, but autonomic functions are not affected
29. A patient with a C7 spinal cord injury undergoing rehabilitation tells the nurse he must
have the flu because he has a bad headache and nausea. The initial action of the nurse is to
a. call the physician
b. check the patient's temperature
c. take the patient's BP
d. elevate the HOB to 90 degrees
30. One indication for surgical therapy of the patient with a spinal cord injury is when
a. there is incomplete cord lesion involvement
b. the ligaments that support the spine are torn
c. a high cervical injury causes loss of respiratory function
d. evidence of continued compression of the cord is apparent
31. A patient is admitted to the emergency department with a possible cervical spinal cord
injury following an automobile crash. During the admission of the patient, the nurse places
the highest priority on
a. maintaining a patent airway
b. assessing the patient for head and other injuries
c. maintaining immobilization of the cervical spine
d. assessing the patient's motor and sensory function
32. A nurse is planning care for a client who suffered a spinal cord injury (SCI) involving a
T12 fracture 1 week ago. The client has no muscle control of the lower limbs, bowel, or
bladder. which of the following should be the nurses' greatest priority?
a. prevention of further damage to the spinal cord
b. prevention of contractures of the lower extremities
c. prevention of skin breakdown of areas that lack sensation
d. prevention of postural hypotension when placing the client in a wheelchair
33. Goals of rehabilitation for the patient with an injury at the C6 level include (select all
that apply)
a. stand erect with leg brace b. feed self with hand devices
c. drive an electric wheelchair d. assist with transfer activities
e. drive adapted van from wheelchair
34. A nurse is caring for a client who experienced a cervical spine injury 3 months ago.
Which of the following types of bladder management methods should the nurse use for this
client?
a. condom catheter b. intermittent urinary catheterization
c. crede's method d. indwelling urinary catheter
35. A patient is admitted with a spinal cord injury at the C7 level. During assessment the
nurse identifies the presence of spinal shock on finding
a. paraplegia with flaccid paralysis b. tetraplegia with total sensory loss
c. total hemiplegia with sensory and motor loss d. spastic tetraplegia with loss of pressure
sensation
36. During the patient's process of grieving for the losses resulting from spinal cord injury,
the nurse
a. helps the patient understand that working through the grief will be a lifelong process
b. should assist the patient to move through all stages of the mourning process to acceptance
c. lets the patient know that anger directed at the staff or the family is not a positive coping
mechanism
d. facilitates the grieving process so that it is completed by the time the patient is discharged
from rehabilitation
37. In planning community education for prevention of spinal cord injuries, the nurse
targets
a. elderly men b. teenage girls
c. elementary school-age children d. adolescent and young adult men
38. In counseling patient with spinal cord lesions regarding sexual function, the nurse
advises a male patient with a complete lower motor neuron lesion that he
a. is most likely to have reflexogenic erections and may experience orgasm if ejaculation occurs
b. may have uncontrolled reflex erections, but that orgasm and ejaculation are usually not
possible
c. has a lesion with the greatest possibility of successful psychogenic erection with ejaculation
and orgasm
d. will probably be unable to have either psychogenic or reflexogenic erections with no
ejaculation or orgasm
39. A patient with paraplegia has developed an irritable bladder with reflex emptying. The
nurse teaches the patient
a. hygiene care for an indwelling urinary catheter
b. how to perform intermittent self-catheterization
c. to empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns
d. that a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary
elimination
40. A nurse is caring for a client who experienced a cervical spine injury 24 hours ago.
which of the following types of prescribed medications should the nurse clarify with the
provider?
a. glucocorticoids b. plasma expanders
c. H2 antagonists d. muscle relaxants
41. When caring for a patient who was admitted 24 hours previously with a C5 spinal cord
injury, which nursing action has the highest priority?
a. Continuous cardiac monitoring for bradycardia
b. Administration of methylprednisolone (Solu-Medrol) infusion
c. Assessment of respiratory rate and depth
d. Application of pneumatic compression devices to both legs
42. A 26-year-old patient with a C8 spinal cord injury tells the nurse, "My wife and I have
always had a very active sex life, and I am worried that she may leave me if I cannot
function sexually." The most appropriate response by the nurse to the patient's comment is
to
a. advise the patient to talk to his wife to determine how she feels about his sexual function.
b. tell the patient that sildenafil (Viagra) helps to decrease erectile dysfunction in patients with
spinal cord injury.
c. inform the patient that most patients with upper motor neuron injuries have reflex erections.
d. suggest that the patient and his wife work with a nurse specially trained in sexual counseling4.
43. A patient with a neck fracture at the C5 level is admitted to the intensive care unit
(ICU) following initial treatment in the emergency room. During initial assessment of the
patient, the nurse recognizes the presence of spinal shock on finding
a. hypotension, bradycardia, and warm extremities.
b. involuntary, spastic movements of the arms and legs.
c. the presence of hyperactive reflex activity below the level of the injury.
d. flaccid paralysis and lack of sensation below the level of the injury.
44. When caring for a patient who experienced a T1 spinal cord transsection 2 days ago,
which collaborative and nursing actions will the nurse include in the plan of care? (Select
all that apply.)
a. Endotracheal suctioning b. Continuous cardiac monitoring
c. Avoidance of cool room temperature d. Nasogastric tube feeding
e. Retention catheter care f. Administration of H2 receptor blockers
45. A patient with a T1 spinal cord injury is admitted to the intensive care unit (ICU). The
nurse will teach the patient and family that
a. use of the shoulders will be preserved.
b. full function of the patient's arms will be retained.
c. total loss of respiratory function may occur temporarily.
d. elevations in heart rate are common with this type of injury.
46. In which order will the nurse perform the following actions when caring for a patient
with possible cervical spinal cord trauma who is admitted to the emergency department?
a. Administer O2 using a non-rebreathing mask.
b. Monitor cardiac rhythm and blood pressure.
c. Immobilize the patient's head, neck, and spine.
d. Transfer the patient to radiology for spinal CT.
46. When caring for a patient who had a C8 spinal cord injury 10 days ago and has a weak
cough effort, bibasilar crackles, and decreased breath sounds, the initial intervention by
the nurse should be to
a. administer oxygen at 7 to 9 L/min with a face mask.
b. place the hands on the epigastric area and push upward when the patient coughs.
c. encourage the patient to use an incentive spirometer every 2 hours during the day.
d. suction the patient's oral and pharyngeal airway.
47. The nurse discusses long-range goals with a patient with a C6 spinal cord injury. An
appropriate patient outcome is
a. transfers independently to a wheelchair.
b. drives a car with powered hand controls.
c. turns and repositions self independently when in bed.
d. pushes a manual wheelchair on flat, smooth surfaces.
48. A patient with a paraplegia resulting from a T10 spinal cord injury has a neurogenic
reflex bladder. When the nurse develops a plan of care for this problem, which nursing
action will be most appropriate?
a. Teaching the patient how to self-catheterize
b. Assisting the patient to the toilet q2-3hr
c. Use of the Credé method to empty the bladder
d. Catheterization for residual urine after voiding
49. Which is most important to respond to in a patient presenting with a T3 spinal injury?
A. Blood pressure of 88/60 mm Hg, pulse of 56 beats/minute
B. Deep tendon reflexes of 1+, muscle strength of 1+
C. Pain rated at 9
D. Warm, dry skin
50. The patient arrives in the emergency department from a motor vehicle accident, during
which the car ran into a tree. The patient was not wearing a seat belt, and the windshield is
shattered. What action is most important for you to do?
A. Determine if the patient lost consciousness.
B. Assess the Glasgow Coma Scale (GCS) score.
C. Obtain a set of vital signs.
D. Use a logroll technique when moving the patient.
51. One month after a spinal cord injury, which finding is most important for you to
monitor?
A. Bladder scan indicates 100 mL.
B. The left calf is 5 cm larger than the right calf.
C. The heel has a reddened, nonblanchable area.
D. Reflux bowel emptying.
52. Which clinical manifestation do you interpret as representing neurogenic shock in a
patient with acute spinal cord injury?
A. Bradycardia B. Hypertension
C. Neurogenic spasticity D. Bounding pedal pulses
53. A male client with a spinal cord injury is prone to experiencing automatic dysreflexia.
The nurse would avoid which of the following measures to minimize the risk of recurrence?
a. Strict adherence to a bowel retraining program
b. Keeping the linen wrinkle-free under the client
c. Preventing unnecessary pressure on the lower limbs
d. Limiting bladder catheterization to once every 12 hours
58. 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
59. The nurse is positioning the female client with increased intracranial pressure. Which
of the following positions would the nurse avoid?
a. Head mildline b. Head turned to the side
c. Neck in neutral position d. Head of bed elevated 30 to 45 degrees
60. A female client has clear fluid leaking from the nose following a basilar skull fracture.
The nurse assesses that this is cerebrospinal fluid if the fluid:
a. Is clear and tests negative for glucose
b. Is grossly bloody in appearance and has a pH of 6
c. Clumps together on the dressing and has a pH of 7
d. Separates into concentric rings and test positive of glucose
62. The nurse is working on a surgical floor. The nurse must logroll a male client following
a:
a. laminectomy. b. thoracotomy.
c. hemorrhoidectomy. d. cystectomy.
63. A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The
nurse should avoid which measure to minimize the risk of recurrence?
1. strict adherence to a bowel retraining program
2. keeping the linen wrinkle free under the client
3. avoiding unnecessary pressure on the lower limbs
4. limiting bladder catheterization to once every 12 hours
64. A nurse is positioning a client with increased ICP. Which position would the nurse
avoid?
A. head midline
B. head turned to the side
C. neck in neutral position
D. head of bed elevated 30-45 degrees
65. A client recovering from a head injury is arousable and participating in care. The nurse
determines that the client understands measures to prevent elevations in intracranial
pressure if the nurse observes the client doing which of the following activities?
A. blowing the nose B. isometric exercises
C. coughing vigorously D. exhaling during repositioning