Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C.
Medical Surgical Nursing Concepts & Practice, 2nd Edition by Susan C.
$2.99
Chapter 23: Care of Patients with Head and Spinal Cord Injuries
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
MULTIPLE CHOICE
| a. | the brain tissue is bruised. |
| b. | no loss of consciousness occurs. |
| c. | there is amnesia related to the incident. |
| d. | there are no subsequent symptoms. |
ANS: C
A concussion is a closed head injury in which there is a brief disruption of consciousness, amnesia, and subsequent headaches that may last for several weeks.
DIF: Cognitive Level: Comprehension REF: 500 OBJ: 1 (theory)
TOP: Concussion: Pathophysiology KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
| a. | a smaller brain, which allows for more movement inside the cranium. |
| b. | fragile vessels more likely to rupture. |
| c. | less cerebrospinal fluid to cushion the brain. |
| d. | less flexibility of the meninges to absorb impact. |
ANS: A
Atrophy of the brain leaves increased intracranial space, allowing increased movement of the brain in the event of head trauma.
DIF: Cognitive Level: Comprehension REF: 501 | Elder Care Points
OBJ: 6 (theory) TOP: Cranial Bleed: Older Adult
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
| a. | Document the presence of rhinorrhea. |
| b. | Inform the physician of the assessment. |
| c. | Test fluid with a glucose Accu-Chek or Dextrostix. |
| d. | Tape a drip pad under the nose. |
ANS: C
The presence of glucose in the fluid from the nose confirms that the fluid is cerebrospinal fluid. Documentation and informing the physician should occur after confirmation of the character of the fluid.
DIF: Cognitive Level: Application REF: 502 OBJ: 1 (theory)
TOP: Rhinorrhea KEY: Nursing Process Step: Implementation
MSC: NCLEX: Physiological Integrity: Reduction of Risk Potential
| a. | Left-sided motor deficit with sluggish right pupil response |
| b. | Right-sided motor deficit with brisk right pupil response |
| c. | Bilateral motor deficit with bilaterally sluggish pupil response |
| d. | Left-sided motor deficit and bilateral PERRLA |
ANS: A
A right-sided injury will cause contralateral (opposite side) motor deficit and ipsilateral (same side) pupillary response.
DIF: Cognitive Level: Application REF: 502 OBJ: 2 (theory)
TOP: Closed Head Injury: Assessment KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
| a. | Increasing respiratory rate |
| b. | Decreasing heart rate |
| c. | Decreasing pulse pressure |
| d. | Decreasing level of consciousness (LOC) |
ANS: D
Assessment of level of consciousness provides the greatest amount of information about neurologic condition. A reduction in level of consciousness may signal the onset of complications in the patient who has had a head injury.
DIF: Cognitive Level: Application REF: 501 | Elder Care Points
OBJ: 2 (theory) TOP: Epidural Hematoma: Signs
KEY: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
Original price was: $30.00.$20.00Current price is: $20.00.
Original price was: $35.00.$25.00Current price is: $25.00.
Original price was: $40.00.$30.00Current price is: $30.00.
Original price was: $200.00.$150.00Current price is: $150.00.
Original price was: $80.00.$60.00Current price is: $60.00.
Original price was: $499.00.$49.00Current price is: $49.00.