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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?
- A. Symptoms will evolve over a period of 1 week.
- B. Monitoring is needed as rapid neurologic deterioration may occur.
- C. The crash cart with defibrillator is kept nearby.
- D. Bleeding continues into the intracerebral area.
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.
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The nurse is caring for a client who has undergone cervical laminectomy surgery. Which nursing intervention(s) is included in the postoperative plan of care? Select all that apply.
- A. Monitor vital signs.
- B. Report an inability to void or an output of less than 8 oz (240 mL) in 8 hours.
- C. Instruct on coughing and deep breathing exercises.
- D. Perform side-to-side range-of-motion exercises of the head and neck.
- E. Perform a neurovascular assessment below the area of the surgery.
- F. Examine dressing for CSF leakage or bleeding.
Correct Answer: A,B,E,F
Rationale: When planning care for a client who has undergone surgery for cervical nerve root decompression, the nurse should include monitoring vital signs, reporting on fluid intake and output, instruction on deep breathing exercises, performing neurovascular assessment below the area of the surgery, and examining the dressing for CSF leakage or bleeding. The nurse should not have the client perform coughing exercises, because these increase pressure within the spinal canal. The nurse should instruct the client to avoid side-to-side rotation of the head for the client with cervical nerve compression and should not perform side-to-side range of motion exercises of the head and neck.
The nurse is caring for a client who requires spine surgery to remove bone fragments and fuse the vertebrae. From which location will bone be taken for the fusion?
- A. Iliac crest
- B. Floating rib
- C. Femur
- D. Mandible
Correct Answer: A
Rationale: To fuse the vertebrae during surgery, the physician uses bone from the iliac crest. The other options are incorrect.
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?
- A. The client is a heart transplant recipient.
- B. The client's medications include warfarin (Coumadin).
- C. The client is HIV positive.
- D. The client has a history of concussions from playing hockey.
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.
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?
- A. Provide a well-balanced diet.
- B. Position the client.
- C. Keep the client hydrated.
- D. Help the client perform exercises.
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.
The nurse learns a client was reported to have a history of basilar skull fracture with otorrhea. What assessment finding does the nurse anticipate?
- A. The client has cerebral spinal fluid (CSF) leaking from the ear.
- B. The client has ecchymosis in the periorbital region.
- C. The client has an elevated temperature.
- D. The client has serous drainage from the nose.
Correct Answer: A
Rationale: Otorrhea means leakage of CSF from the ear. The client with a basilar skull fracture can create a pathway from the brain to the middle ear due to a tear in the dura. As a result, the client can have cerebral spinal fluid leak from the ear. The nurse may assess clear fluid in the ear canal. Ecchymosis and periorbital edema can be present as a manifestation of bruising from the head injury. An elevated temperature may occur from the head injury and is monitored closely. The client may have serous drainage from the nose especially immediately following the injury.