After falling 20’, a 36-year-old man sustains a C6 fracture with spinal cord transaction. Which other findings should the nurse expect?
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Solution
Quadriplegia with gross arm movement and diaphragmatic breathing
A client with a spinal cord injury at levels C5 to C6 has quadriplegia with gross arm movement and diaphragmatic breathing.
Option B: Injury levels C1 to C4 leads to quadriplegia with total loss of respiratory function.
Option C: Paraplegia with intercostal muscle loss occurs with injuries at T1 to L2.
Option D: Injuries below L2 cause paraplegia and loss of bowel and bladder control.
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?
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Solution
Epidural hematoma
An epidural hematoma occurs when blood collects between the skull and the dura mater.
Option A: In a subdural hematoma, venous blood collects between the dura mater and the arachnoid mater.
Option B: In a subarachnoid hemorrhage, blood collects between the pia mater and arachnoid membrane.
Option D: A contusion is a bruise on the brain’s surface.
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?
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Solution
Activity of the brain
An EEG measures the electrical activity of the brain.
Options A and B: Extent of intracranial bleeding and location of the injury site would be determined by CT or MRI.
Option D: Percent of functional brain tissue would be determined by a series of tests.
Which neurotransmitter is responsible for may of the functions of the frontal lobe?
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Solution
Dopamine
The frontal lobe primarily functions to regulate thinking, planning, and affect. Dopamine is known to circulate widely throughout this lobe, which is why it’s such an important neurotransmitter in schizophrenia.
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?
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Solution
“Wake him every hour and assess his orientation to person, time, and place.”
Changes in LOC may indicate expanding lesions such as subdural hematoma; orientation and LOC are frequently assessed for 24 hours.
Option A: A keyhole pupil is found after iridectomy.
Option B: Profuse or projectile vomiting is a symptom of increased ICP and should be reported immediately.
Option D: A slight headache may last for several days after concussion; severe or worsening headaches should be reported.
A 40-year-old paraplegic must perform intermittent catheterization of the bladder. Which of the following instructions should be given?
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Solution
“Clean the meatus with soap and water.”
Intermittent catheterization may be performed chronically with clean technique, using soap and water to clean the urinary meatus.
Option A: The meatus is always cleaned from front to back in a woman, or in expanding circles working outward from the meatus in a man.
Option B: It isn’t necessary to measure the urine.
Option C: The catheter doesn’t need to be rotated during removal.
A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?
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Solution
Hypertension and bradycardia
Hypertension, bradycardia, anxiety, blurred vision, and flushing above the lesion occur with autonomic dysreflexia due to uninhibited sympathetic nervous system discharge. The other options are incorrect.
A client has a cervical spine injury at the level of C5. Which of the following conditions would the nurse anticipate during the acute phase?
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Solution
The need for mechanical ventilation
The diaphragm is stimulated by nerves at the level of C4. Initially, this client may need mechanical ventilation due to cord edema. This may resolve in time.
Options A, B, and C: Absent corneal reflexes, decerebrate posturing, and hemiplegia occur with brain injuries, not spinal cord injuries.
A client with a T1 spinal cord injury arrives at the emergency department with a BP of 82/40, pulse 34, dry skin, and flaccid paralysis of the lower extremities. Which of the following conditions would most likely be suspected?
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Solution
Neurogenic shock
Loss of sympathetic control and unopposed vagal stimulation below the level of injury typically cause hypotension, bradycardia, pallor, flaccid paralysis, and warm, dry skin in the client in neurogenic shock.
Option A: Autonomic dysreflexia occurs after neurogenic shock abates.
Option B: Hypervolemia is indicated by rapid and bounding pulse and edema.
Option D: Signs of sepsis would include elevated temperature, increased heart rate, and increased respiratory rate.
During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
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Solution
Put the client in the high-Fowler’s position
Putting the client in the high-Fowler’s position will decrease cerebral blood flow, decreasing hypertension.
Options A, B, and C: Elevating the client’s legs, putting the client flat in bed, or putting the bed in the Trendelenburg’s position places the client in positions that improve cerebral blood flow, worsening hypertension.