Nokea
The nurse is employed in the neurosurgeon's office assisting the physician in teaching. The nurse is instructing a client who is very anxious, stating, 'What will happen if the conservative treatment for the degenerative changes in my spine does not help my lumbar pain?' The nurse is most correct to turn the teaching to which surgical procedure?
- A. A discectomy
- B. A laminectomy
- C. A spinal fusion
- D. Aggressive traction
Correct Answer: C
Rationale: The nurse is most correct to provide teaching on a spinal fusion aimed to stabilize the vertebrae weakened by degenerative joint changes such as osteoarthritis and by a laminectomy. A discectomy provides pain relief by the removal of a ruptured disk. A laminectomy is the removal of the posterior arch of a vertebra to expose the spinal cord. From this point, the surgeon can remove a herniated disk, tumor, bone fragments, etc. Aggressive traction is not a surgical option.
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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?
- A. Acetaminophen may be administered for aches.
- B. Observe for any signs of behavioral changes.
- C. A light meal may be eaten if desired.
- D. Follow up with regular physician is encouraged.
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.
The nurse is caring for a client with a head injury after a fall. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?
- A. Change in the level of consciousness (LOC)
- B. Signs of increased intracranial pressure (IICP)
- C. Halo sign
- D. Swelling
Correct Answer: C
Rationale: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage.
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 admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury?
- A. Cervical collar
- B. Cast
- C. Traction with weights and pulleys
- D. Turning frame
Correct Answer: C
Rationale: Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client's position without altering the alignment of the spine.
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.