Nokea
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.
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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.
The nurse is caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury?
- A. Radiography
- B. Myelography
- C. Neurologic examination
- D. Computed tomography (CT) scan
Correct Answer: C
Rationale: A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma.
The nurse is working in the rehabilitative setting caring for tetraplegia and paraplegia clients. When instructing family members on the difference between the sites of impairment, which location should the nurse explain differentiates the two disorders?
- A. The second cervical vertebrae
- B. The first thoracic vertebrae
- C. The seventh thoracic vertebrae
- D. The first lumbar vertebrae
Correct Answer: B
Rationale: Tetraplegia is the impairment of all extremities and the trunk when there is a spinal injury at or above the first thoracic vertebrae. Paraplegia is the impairment of all extremities below the first thoracic vertebrae.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
- A. The client has periorbital edema and ecchymosis.
- B. The client's vital signs are temperature, 100.9?°F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
- C. The client's level of consciousness has improved.
- D. The client prefers to rest in the semi-Fowler's position.
Correct Answer: B
Rationale: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9?°F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.
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.