Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim
Introductory Medical Surgical Nursing 11th Edition by Barbara K. Tim
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Chapter 39, Caring for Clients With Head and Spinal Cord Trauma
Complete Chapter Questions With Answers
Sample Questions Are Posted Below
| 1. | The nurse is caring for a client with a head injury after a fall from a hayloft. 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 | |
| Ans: | C | |
| Feedback: | ||
| 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. | ||
| 2. | Which of the following types of hematoma results from venous bleeding with blood gradually accumulating in the space below the dura? | |
| A) | Epidural | |
| B) | Subdural | |
| C) | Intracerebral | |
| D) | Cerebral | |
| Ans: | B | |
| Feedback: | ||
| A subdural hematoma results from venous bleeding, with blood gradually accumulating in the space below the dura. An epidural hematoma stems from arterial bleeding, usually from the middle meningeal artery, and blood accumulation above the dura. An intracerebral hematoma is bleeding within the brain that results from an open or closed head injury or from a cerebrovascular condition such as a ruptured cerebral aneurysm. A cerebral hematoma is bleeding within the skull. | ||
| 3. | You are caring for a client with a spinal cord injury. What test reveals the level of spinal cord injury? | |
| A) | Radiography | |
| B) | Myelography | |
| C) | Neurologic examination | |
| D) | Computed tomography (CT) scan | |
| Ans: | C | |
| Feedback: | ||
| A neurologic examination reveals the level of spinal cord injury. Radiography, myelography, and a CT scan show the evidence of fracture or compression of one or more vertebrae, edema, or a hematoma. | ||
| 4. | The nurse is admitting a client from the emergency department with a reported spinal cord injury. What device would the nurse expect to be used to provide correct vertebral alignment and to increase the space between the vertebrae in a client with spinal cord injury? | |
| A) | Cervical collar | |
| B) | Cast | |
| C) | Traction with weights and pulleys | |
| D) | Turning frame | |
| Ans: | C | |
| Feedback: | ||
| Traction with weights and pulleys is applied to provide correct vertebral alignment and to increase the space between the vertebrae. A cast and a cervical collar are used to immobilize the injured portion of the spine. A turning frame is used to change the client’s position without altering the alignment of the spine. | ||
| 5. | A client with impaired physical mobility has been hospitalized. What nursing intervention helps reduce the potential for formation of thrombi and renal calculi in a client with impaired physical mobility? | |
| A) | Provide a well-balanced diet. | |
| B) | Position the client. | |
| C) | Keep the client hydrated. | |
| D) | Help the client perform exercises. | |
| Ans: | C | |
| Feedback: | ||
| 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. | ||
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