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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.
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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 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 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.
A middle-aged client has scheduled a sick visit to the physician's office, reporting symptoms of lower back pain with exacerbation upon movement. The nurse draws a picture of the components of the spinal cord and surrounding structures and shows potential causes of the pain. Which area of the drawing would the nurse emphasize?
- A. Spinal cord pathway
- B. Nucleus pulposus
- C. Bony vertebrae
- D. Associated musculature
Correct Answer: B
Rationale: Pressure on the spinal nerve roots result from trauma, herniated disks, and tumors. The nurse would emphasize the nucleus pulposus as a common area of problem. Stress caused by poor body mechanics, age, or disease weakens an area in the vertebra, causing the spongy center of the vertebra, the nucleus pulposus, to swell and herniate. The spinal cord pathway can cause symptoms of numbness and tingling. The bony vertebrae can present symptoms when fractures and bony fragments occur. Associated musculature pulling can place the vertebrae out of alignment causing symptoms.
The nurse is caring for a client immediately after a spinal cord injury. Which assessment finding is essential when caring for a client in spinal shock with injury in the lower thoracic region?
- A. Numbness and tingling
- B. Respiratory pattern
- C. Pulse and blood pressure
- D. Pain level
Correct Answer: C
Rationale: Spinal shock is a loss of sympathetic reflex activity below the level of the injury within 30 to 60 minutes after insult. In addition to the paralysis, manifestations include pronounced hypotension, bradycardia, and warm, dry skin. Numbness and tingling and pain are not as high of a concern at this time due to the cord injury. Because the level of impairment is below the first thoracic vertebrae, respiratory failure is not a concern.