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A trauma nurse is caring for a patient that sustained trauma to the head. She notices that the patient has a "blown pupil" (one pupil is fixed a dilated). This is caused by intracranial swelling and brain herniation. A blown pupil is caused by disruption of which cranial nerve?
Place a tongue-blade in the patient's mouth to prevent blockage of the airway.
A patient in the hospital for observation after a presumed seizure is found thrashing about in his room. Which of the following would be an improper intervention?
The patient should be placed on droplet precautions.
You are working in the emergency department when a college freshman is brought in by his roommate. The freshman has a severe headache, stiff neck, subjective fever and his roommate had to pull over en route to the hospital to let the patient vomit. The lights of the ER triage area seem to bother his eyes. Which of the following is an important part of caring for this patient?
A gentleman from Peru is brought by his wife to the clinic. He does not speak English and she is translating for him. You learn that he was a manganese miner for over twenty years. This gentleman is at particular risk of developing symptoms of which of the following diseases?
Equal pupillary constriction in response to light
You are the nurse assigned to perform an eye assessment on an 80-year-old client. Which of the following findings during the assessment is considered normal?
Loss of lens elasticity
Which of the following physiologic changes would be expected in a patient with presbyopia?
"The lens is normally transparent
A patient has a question about a recent eye exam. Which of the following statements would be an accurate response to inquiry?
A patient with glaucoma has medication prescribed to decrease intraocular pressure. Which of the following medication should be questioned by the nurse?
Encouraging compliance with drug therapy to prevent loss of vision
A client with history of glaucoma was diagnosed by the community nurse as experiencing Visual Sensory/Perceptual Alterations R/T increased intraocular pressure. The plan of care should focus on:
A patient has a normal sensory change that results in diminished sense of taste. How would this be documented
CN IX and CN VII
A client has noticed a decrease in taste sensation. Which of the following cranial nerves are most likely involved
Damage to cranial nerve I
A 78-year-old client is admitted to the Emergency Department (ED) via emergency medical service (EMS) with complaints of severe diarrhea with resultant weakness and signs of dehydration. Discussion with the significant other reveals that the patient continually eats spoiled foods. Which of the following might be most directly related to this patient's behavior?
Reposition the client to avoid neck flexion
An 18-year-old client is admitted with a closed head injury sustained in a MVA. His intracranial pressure (ICP) shows an upward trend. Which intervention should the nurse perform first?
Rapid dilantin administration can cause cardiac arrhythmias
A client with a subarachnoid hemorrhage is prescribed a 1,000-mg loading dose of Dilantin IV. Which consideration is most important when administering this dose?
Evaluate urine specific gravity
A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially?
Immobilize the client's head and neck
A client comes into the ER after hitting his head in an MVA. He's alert and oriented. Which of the following nursing interventions should be done first?
Raise the head of the bed immediately to 90 degrees
A 22-year-old client with quadriplegia is apprehensive and flushed, with a blood pressure of 210/100 and a heart rate of 50 bpm. Which of the following nursing interventions should be done first?
To immobilize the surgical spine
A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
Laceration of the middle meningeal artery
A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions?
Check the fluid for dextrose with a dipstick
A 23-year-old client has been hit on the head with a baseball bat. The nurse notes clear fluid draining from his ears and nose. Which of the following nursing interventions should be done first?
A client with a high cervical spine injury
Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
Put the client in the high-Fowler's position
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
"Wake him every hour and assess his orientation to person, time, and place
An 18-year-old client was hit in the head with a baseball during practice. When discharging him to the care of his mother, the nurse gives which of the following instructions?
Activity of the brain
The nurse is discussing the purpose of an electroencephalogram (EEG) with the family of a client with massive cerebral hemorrhage and loss of consciousness. It would be most accurate for the nurse to tell family members that the test measures which of the following conditions?
A client arrives at the ER after slipping on a patch of ice and hitting her head. A CT scan of the head shows a collection of blood between the skull and dura mater. Which type of head injury does this finding suggest?
Quadriplegia with gross arm movement and diaphragmic breathing
After falling 20', a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect
The nurse is caring for the client in the ER following a head injury. The client momentarily lost consciousness at the time of the injury and then regained it. The client now has lost consciousness again. The nurse takes quick action, knowing this is compatible with
Limiting bladder catherization to once every 12 hours
A client with a spinal cord injury is prone to experiencing autonomic dysreflexia. The nurse would avoid which of the following measures to minimize the risk of recurrence?
Inability to elicit a Babinski's reflex
The nurse is evaluating neurological signs of the male client in spinal shock following spinal cord injury. Which of the following observations by the nurse indicates that spinal shock persists?
Unequal pupil size
A client is at risk for increased ICP. Which of the following would be a priority for the nurse to monitor?
Slow, irregular respirations
Which of the following respiratory patterns indicate increasing ICP in the brain stem?
Encourage the client to hyperventilate
Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg?
Decrease in LOC
A client has signs of increased ICP. Which of the following is an early indicator of deterioration in the client's condition?
Wrap her hands in soft "mitten" restraints
A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her IV line. Which nursing intervention protects the client without increasing her ICP?
Back arched; rigid extension of all four extremities.
Which of the following describes decerebrate posturing?
Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma score
A client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?
Dilated non reactive pupils
A client has been pronounced brain dead. Which findings would the nurse assess?
abnormal posturing that involves rigidity, flexion of the arms, clenched fists, and extended legs.
seizures are divided into two broad categories: generalized and partial (also called local or focal).
partial seizures are produced (at least initially) by electrical impulses in a relatively small part of the brain.
short loss of consciousness (just a few seconds) with few or no symptoms. The patient, most often a child, typically interrupts an activity and stares blankly. These seizures begin and end abruptly and may occur several times a day. Patients are usually not aware that they are having a seizure, except that they may be aware of "losing time."
sporadic jerks, usually on both sides of the body. Patients sometimes describe the jerks as brief electrical shocks. When violent, these seizures may result in dropping or involuntarily throwing objects.
sudden and general loss of muscle tone, particularly in the arms and legs, which often results in a fall.
Basilar skull fractures
Caused by a blow to the back of the head, characteristic signs: blood in the sinuses; a clear fluid called cerebrospinal fluid (CSF) leaking from the nose or ears; raccoon eyes
dural and arachnoid membranes and their associated blood vessels are readily torn by the impact and fractured bone fragments
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