Nokea
The nurse is working on the neurologic unit at a local hospital. The nurse has four clients assigned who sustained head injuries as a result of an industrial accident. Which client would the nurse anticipate the physician sending for specialized care?
- A. The client with history of seizures
- B. The client who was in a bike accident last summer
- C. The client who played soccer in college
- D. The client whose father has Parkinson's disease
Correct Answer: C
Rationale: The client who has history of playing many years of a physical sport such as soccer and use the head to redirect the ball may have had years of injury to the brain. When concussions occur repetitively, even though they may have not shown injury at that time, chronic traumatic encephalopathy may result. Chronic traumatic encephalopathy, which can produce neurodegeneration, will need specialized care. The client who has a history of seizures may have no brain injury. The client who was in a previous accident may have had injury, but it is not of a repetitive nature. The client with a father who has Parkinson's disease will have regular follow-up care.
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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 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 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 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 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.