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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?
- A. Coup injury
- B. Contusion
- C. Head injury
- D. Contrecoup 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.
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The nurse is evaluating the transmission of a report from a paramedic unit to the emergency department. The medic reports that a client is unconscious with edema of the head and face and Battle sign. What clinical picture would the nurse anticipate?
- A. Edema to the head and a blackened eye
- B. Edema to the head with a large scalp laceration
- C. Edema to the head with fixed pupils
- D. Edema to the head with bruising of the mastoid process
Correct Answer: D
Rationale: Battle sign is the presence of bruising of the mastoid process behind the ear. It is not related to periorbital bleeding, lacerations, or fixed pupils.
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.
The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration?
- A. Extradural hematoma
- B. Epidural hematoma
- C. Subdural hematoma
- D. Intracranial hematoma
Correct Answer: B
Rationale: An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. It is characterized by rapidly progressive neurologic deterioration.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
- A. Extreme thirst
- B. Intake and output
- C. Nutritional status
- D. Body temperature
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.
A nurse is caring for a client with a spinal cord injury from a motorcycle accident. The nurse is instructing on the benefits of stem cell transplantation therapy. Which statement(s) should the nurse include in the teaching? Select all that apply.
- A. Cells in the spinal cord may regenerate spontaneously when injured.
- B. Stem cells can cause the damaged spinal nerves to repair themselves.
- C. Stems cells can be harvested from an individual's own bone marrow.
- D. Harvested stem cells can be reimplanted into the area surrounding the injury.
- E. Stem cells can replace the damaged nerve cells when they are transplanted.
Correct Answer: C,D,E
Rationale: When teaching the client about the benefits of stem cell transplantation therapy, the nurse should explain how stem cells are used to treat a spinal cord injury. In particular, the education should emphasize that stem cells are harvested from the client's own bone marrow and can be reimplanted into the area surrounding the injury, replacing the damaged nerve cells when they are transplanted. The spinal cord loses the ability to regenerate when injured, and stem cells replace the injured spinal nerves rather than causing them to repair themselves, so the nurse would be incorrect to include these statements when discussing the therapy with the client.