Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Caring for Clients With Head and Spinal Cord Trauma

Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Caring for Clients With Head and Spinal Cord Trauma Related

Review Timby's Introductory Medical-Surgical Nursing Thirteenth, North American Edition - Caring for Clients With Head and Spinal Cord Trauma related questions and content

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?

  • A. Understand that headaches are uncommon.
  • B. You can cover the incision with your hair.
  • C. You can expect swelling above the incision.
  • D. Expect sensory changes, such as hearing a clicking sound, around the bone flap.
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.

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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.

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 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.

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.

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.

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