HEAD INJURIES, BRAIN INJURY, SPINAL

CORD INJURY
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An 18-year-old client was hit in the head with a baseball during practice. * 1 point

When discharging him to the care of his mother, the nurse gives which of
the following instructions?

a. “Watch him for keyhole pupil the next 24 hours.”

b. “Expect profuse vomiting for 24 hours after the injury.”

c. “Wake him every hour and assess his orientation to person, time, and place.”

d. “Notify the physician immediately if he has a headache.”

A male client has an impairment of cranial nerve II. Specific to this * 1 point

impairment, the nurse would plan to do which of the following to ensure

client to ensure client safety?

a. Speak loudly to the client

b. Test the temperature of the shower water

c. Check the temperature of the food on the delivery tray.

d. Provide a clear path for ambulation without obstacles

An 18-year-old client is admitted with a closed head injury sustained in a * 1 point

MVA. His intracranial pressure (ICP) shows an upward trend. Which

intervention should the nurse perform first?

a. Reposition the client to avoid neck flexion

b. Administer 1 g Mannitol IV as ordered

c. Increase the ventilator’s respiratory rate to 20 breaths/minute

d. Administer 100 mg of pentobarbital IV as ordered

A 22-year-old client with quadriplegia is apprehensive and flushed, with a * 1 point

blood pressure of 210/100 and a heart rate of 50 bpm. Which of the

following nursing interventions should be done first?

a. Place the client flat in bed

b. Assess patency of the indwelling urinary catheter

c. Give one SL nitroglycerin tablet

d. Raise the head of the bed immediately to 90 degrees

A 23-year-old client has been hit on the head with a baseball bat. The nurse * 1 point

notes clear fluid draining from his ears and nose. Which of the following
nursing interventions should be done first?

a. Position the client flat in bed

b. Check the fluid for dextrose with a dipstick

c. Suction the nose to maintain airway patency

d. Insert nasal and ear packing with sterile gauze

A client with a C6 spinal injury would most likely have which of the * 1 point

following symptoms?

a. Aphasia

b. Hemiparesis

c. Paraplegia

d. Tetraplegia

A client is admitted with a spinal cord injury at the level of T12. He has * 1 point
limited movement of his upper extremities. Which of the following
medications would be used to control edema of the spinal cord?

a. Acetazolamide (Diamox)

b. Furosemide (Lasix)

c. Methylprednisolone (Solu-Medrol)

d. Sodium bicarbonate

Which of the following interventions describes an appropriate bladder * 1 point

program for a client in rehabilitation for spinal cord injury?

a. Insert an indwelling urinary catheter to straight drainage

b. Schedule intermittent catheterization every 2 to 4 hours

c. Perform a straight catheterization every 8 hours while awake

d. Perform Crede’s maneuver to the lower abdomen before the client voids.
 A client has been pronounced brain dead. Which findings would the nurse * 1 point
assess? Select all that apply.

a. Decerebrate posturing

b. Dilated nonreactive pupils

c. Deep tendon reflexes

d. Absent corneal reflex

A client comes into the ER after hitting his head in an MVA. He’s alert and * 1 point
oriented. Which of the following nursing interventions should be done first?

a. Assess full ROM to determine extent of injuries

b. Call for an immediate chest x-ray

c. Immobilize the client’s head and neck

d. Open the airway with the head-tilt-chin-lift maneuver

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