Chapter - 075 Neurologic Trauma

Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive
Outcomes, 7th Edition
Chapter 75: Management of Clients with Neurologic Trauma
MULTIPLE CHOICE
1. An elderly client who was found unresponsive at home now opens his eyes when spoken to
and answers simple questions when asked; and left alone usually sleeps. The nurse would
document this information in the Glasgow Coma Scale using the categories of
a. eye opening and best verbal response.
b. eye opening and motor activity.
c. motor activity and motor response.
d. best verbal response and best motor response.
ANS: a
Eye opening: If the eyes are closed, call the client's name. Best verbal response: Verbal responses
assess the client's orientation to self, environment, and time.
DIF: Cognitive Level: Application REF: Text Reference: 2199, Box 75-2;
TOP: Nursing Process Step: Assessment
MSC: NCLEX: Physiological Integrity
2. The nurse explains that irreversible brain tissue damage is probable when the blood flow to
the brain is reduced by
a. 10%.
b. 30%.
c. 40%.
d. 60%.
ANS: d
When the blood flow to the brain is reduced by 60% the electroencephalogram (EEG) pattern
changes and the client is at risk for significant brain tissue damage.
DIF: Cognitive Level: Knowledge REF: Text Reference: 2191

TOP: Nursing Process Step: Intervention
3. During assessment of a head-injured client, the nurse notes that the arms, wrists, and fingers
are flexed, and the arms are adducted. The client is demonstrating
a. normal flexion in comatose individuals.
b. spasticity.
c. decerebrate posturing.
d. decorticate posturing.
ANS: d
Chapter 75: Management of Clients with Neurologic Trauma 2
When the intracranial pressure (ICP) is increased at the cortical level, abnormal flexion
(decorticate) posturing is seen.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2199, Box 75-2;
4. The nurse recognizes a particular abnormal posturing that indicates the poorest prognosis in a
brain-injured patient is
a. abnormal flexion.
b. abnormal extension.
c. unilateral flaccidity.
d. bilateral flaccidity.
ANS: d
Bilateral flaccidity is a complete absence of motor response and yields the lowest subscore on
the Glasgow Coma Scale.
5. The client who is unconscious following a fall has baseline blood pressure of 120/70. The
most recent blood pressure reading is 90/60; the nurse should
a. increase the patient's intravenous (IV) fluids.
b. raise the client's feet 30 degrees.
c. retake the blood pressure in 15 minutes.
d. notify the physician immediately.
ANS: d
If the physician has not left orders to treat blood pressure changes, notification must occur if the
blood pressure range is less than 100 or more than 150 mm Hg systolic.
DIF: Cognitive Level: Application REF: Text Reference: 2119

6. When the nurse assesses brain tissue extruding through an unstable skull fracture, it is
documented as
a. transcalvarial herniation.
b. central transtentorial herniation.
c. cingulate herniation.
d. tonsillar herniation.
ANS: a
Transcalvarial herniation describes the situation in which brain tissue is extruded through an
unstable skull fracture.
Elsevier items and derived items © 2005 by Elsevier Inc.


7. When the client being treated with a hypothermia blanket begins to shiver, the nurse should
a. increase the O2 to 4 L/minute.
b. take off the hypothermia blanket.
c. give prescribed antipyretic medication.
d. assess the blood pressure for a widening pulse pressure.
ANS: b
When the client begins to shiver, the metabolic demands increase, robbing the brain of needed
oxygen and nutrients. A client undergoing hypothermic treatment should be cool, but not to the
point of shivering.

8. Vital signs on a brain-injured client 1 hour ago were T 98.8°, P 76, BP 124/72. When the
nurse takes a current set of vital signs that are T 98.4°, P 56, BP 160/54, the nurse should
a. lower the head of the bed.
b. prepare to administer lidocaine.
c. begin oxygen via nasal cannula.
d. notify the physician immediately.
ANS: d
Cushing's triad, or increased systolic blood pressure with widened pulse pressure, and
bradycardia, is a late response and indicates severe increased ICP with the failure of
autoregulation. If the physician has not left orders to cover blood pressure changes, then you
must notify him or her if the blood pressure is less than 100 or more than 150 mm Hg systolic.
DIF: Cognitive Level: Analysis REF: Text Reference: 2192

9. The nursing care that should be included in the care of a recently stabilized client who had
head trauma is to
a. encourage full fluids.
b. administer steroids in high continuous doses.
c. assess vital signs and neurologic status hourly.
d. maintain the head of the bed in a flat position.
ANS: c
Evaluate the client's response to treatment as often as every 15 minutes, progressing to hourly,
then every 2 to 4 hours, and every 8 hours as the client improves.
DIF: Cognitive Level: Comprehension REF: Text Reference: 2200


10. When the nurse notes that a client with skull fracture has clear fluid draining from his nose,
the nurse should initially
a. notify the physician.
b. test the fluid for glucose.
c. send a specimen of the fluid for culture.
d. encourage the client to blow his nose.
ANS: b
Clinical manifestations of skull fracture include cerebrospinal fluid (CSF) or other fluid draining
from the ear or nose. CSF drainage is clear and tests positive for glucose.

11. The nurse explains that the most serious complication of increased ICP is
a. ventricular arrhythmias.
b. coma.
c. motor deficits.
d. brain herniation.
ANS: d
Herniation syndromes occur late in the courseof increased ICP and represent the body's attempt
to restore normal brain volume and pressure through displacement of blood, brain tissue, or CSF.
Herniation, regardless of the type, always constitutes an emergency.

12. In order to assess motor response, the nurse performing a neurologic assessment on a client
in a coma would ask the client to
a. grasp the nurse's fingers.
b. cough and deep breathe.
c. wiggle the toes.
d. repeat a phrase.
ANS: c
Motor responses are assessed by asking the client to follow specific commands, such as "wiggle
your toes." Do not ask the client to squeeze your hand because grasp is a reflexive response that
occurs in clients with head injury.

13. The emergency department nurse should position the client with cranial injuries
a. supine with the bed flat.
b. supine with the head of the bed elevated 30 degrees.
c. lying on the side with the head raised 45 degrees.
d. in high-Fowler's position.
ANS: b
Place the client with cranial injures supine with the head elevated 30 degrees unless
contraindicated (e.g., some spinal injuries, some aneurysms).

14. When the nurse caring for a client using an ICP monitor reads ICP as 20 mm Hg, the nurse
would interpret this as
a. lower than normal.
b. normal.
c. higher than normal.
d. an incorrect reading.
ANS: c
The ICP reading should be less than 15 mm Hg.

15. The nurse reminds a group of high school students that the most common cause of spinal
cord injury (SCI) is
a. myelitis.
b. vascular disease.
c. trauma.
d. cervical spondylosis.
ANS: c
SCIs most often occur as a result of injury to the vertebrae.

MSC: NCLEX: Health Promotion and Maintenance
16. When the client who has been in flaccid spinal shock dorsiflexes the great toe and fans the
other toes when the sole of his foot is stroked, the nurse is
a. distressed, because this indicates deterioration.
b. alarmed, because this indicates increased ICP.
c. pleased, because this indicates a reduction of spinal shock.

d. alerted, because this indicates possible meningeal irritation.

ANS: c
When a client previously in flaccid spinal shock begins to exhibit flexion, it is an indication of
the reduction of spinal shock.

17. When the client who has an incomplete lesion of the spinal cord complains of more weakness
in his upper extremities than in his lower extremities, the nurse recognizes these
manifestations to be consistent with
a. anterior cord syndrome.
b. Brown-Séquard syndrome.
c. cervical cord syndrome.
d. central cord syndrome.
ANS: d
In central cord syndrome, the weakness is caused by edema and hemorrhage in the central area
of the cord, which is predominantly occupied by nerve tracts to the hands and arms.

18. Following a spinal cord injury, assessment revealed left-side motor paralysis with loss of
vibratory and position sense, and right-side loss of pain and temperature sensation. The nurse
recognizes the spinal cord syndrome of
a. anterior cord syndrome.
b. central cord syndrome.
c. Brown-Séquard syndrome.
d. spinal shock syndrome.
ANS: c
Brown-Séquard syndrome is caused by lateral hemisection of the cord. This results in ipsilateral
motor paralysis, loss of vibratory and position sense, and contralateral loss of pain and
temperature sensation.

19. When a client arrives in the emergency department after being involved in a motor vehicle
accident exhibiting a complete loss of motor, sensory, autonomic, and reflex activity below
the injury level with concurrent hypotension and bradycardia, the nurse can determine if he is
experiencing spinal shock by assessing
a. the pupillary response.

b. his blood pressure and pulse rate.

c. for muscle spasm.
d. the presence of bowel sounds.
ANS: b
The immediate response to cord transection is called spinal shock or post-traumatic areflexia.
The spinal cord–injured person experiences complete loss of skeletal muscle function, bowel and
bladder tone, sexual function, and autonomic reflexes. Loss of venous return and hypotension
also occur.

20. The nurse is assessing a client for manifestations of recovery from spinal shock. Which of the
following assessment findings would indicate that spinal shock is resolving?
a. Hyperreflexia
b. Flaccid paralysis
c. Urinary retention
d. Loss of Babinski’s response
ANS: a
Indications that spinal shock is resolving include the return of reflexes, the development of
hyperreflexia rather than flaccidity, and the return of reflex emptying of the bladder.

21. A client with a spinal cord lesion is experiencing recurrent and painful spasms of his lower
limbs. The nurse intervenes by
a. massaging the client's legs.
b. administering pain medication.
c. assessing for manifestations of bladder distention.
d. placing the client in the sitting position.
ANS: c
Reflex spasms may be triggered by extrinsic or visceral stimuli, such as a distended bladder.

22. The nurse explains to a family that immediate medical-surgical stabilization after a severe
cervical injury would include
a. skeletal traction.
b. spinal fusion.
c. cervical brace.

d. halo jacket.
ANS: a
In the emergency department a person who has sustained a severe cervical injury should be
placed immediately in skeletal traction to immobilize the cervical spine and reduce the fracture
and dislocation.

23. When a client with upper motor neuron damage following a spinal cord injury is
experiencing a neurogenic bowel, the nurse would alter the plan of care to include
a. administering soapsuds enema daily.
b. manually disimpacting daily.
c. administering suppository daily.
d. administering laxative daily.
ANS: c
The bowel movements of clients with upper motor neuron damage aregenerally regulated with
suppositories or digital stimulation every day or every other day to limit the risk of autonomic
dysreflexia.

24. When the client is improving from spinal shock and has a reflexive emptying of the bladder,
the nurse should
a. replace the indwelling catheter.
b. increase the fluid intake.
c. check for postvoid residual.
d. check the urine for presence of blood.
ANS: c
When spinal shock subsides and clients begin to empty their bladder by reflex, a postvoid
catheterization should be formed to check for residual.

25. The nurse encourages the client who has sustained a C5 complete spinal cord injury that he
should anticipate that he will be able to
a. dress totally independently.
b. learn to type or use a computer.
c. feed himself.
d. self-catheterize.

ANS: b
People with a C5 transection will be able to dress the upper trunk, propel a wheelchair after
rehabilitative surgery, learn to type or write, and assist with getting in and out of bed.
DIF: Cognitive Level: Application REF: Text Reference: 2222, Table 75-2;
26. A male client with a spinal cord injury at the level of C5 is despondent relative to the
termination of sexual relations due to his injury. The nurse counsels that erections are
possible with
a. manual stimulation.
b. visual imagery.
c. penile implant.
d. ice pack to the scrotum.
ANS: c
A penile implant is one avenue to continuation of sexual activity.

MSC: NCLEX: Psychosocial Integrity
27. While caring for a spinal cord–injured client, the nurse notes that he is flushed and sweating
profusely, complaining of headache and nausea, and that his blood pressure is elevated with a
slow pulse rate. The initial intervention should be to
a. notify the physician.
b. elevate the head of the bed to a sitting position.
c. check for a distended bladder.
d. administer antihypertensive medication.
ANS: b
If autonomic dysreflexia does occur, elevate the head of the bed to a sitting position immediately,
check the blood pressure, check for possible sources of irritation, remove the stimulus if it can be
done quickly, administer antihypertensive medications per order, if needed, and notify the
physician.

28. The nurse assesing oval pupils in a comatose client, documents and reports this change
because it indicates
a. brain herniation.
b. optic involvement that may lead to blindness.
c. increasing ICP.
d. imminent seizure.

ANS: c
Pupils that are oval rather than round indicate an increase in ICP.

29. In order to assess for the effectiveness of IV mannitol for the client with cerebral edema, the
nurse will monitor for increase in
a. urinary output.
b. rate and depth of respirations.
c. restlessness.
d. muscle spasticity.
ANS: c
IV mannitol is a hypertonic dehydrator that pulls interstitial fluid into the circulating volume and
ultimately into the urine output.

30. When the client who experienced a spinal injury at the T12 level complains to the nurse of
severe pain in her legs, the nurse should
a. notify the physician immediately.
b. administer a nonnarcotic analgesic.
c. obtain an order for a steroid preparation.
d. explain that this sensation is “phantom pain.”
ANS: b
Clients with spinal injuries may experience pain at the level of the injury that radiates along
spinal nerves originating in the area. Pain most often occurs in the lower extremities. Analgesics
such as aspirin and nonsteroidal anti-inflammatory agents may be prescribed.

31. The client with a spinal cord injury asks the nurse why he must stand on the tilt table every
day. The nurse should base the answer on the fact that weight-bearing
a. improves circulation.
b. strengthens muscles in the legs.
c. prevents bone demineralization.
d. decreases leg spasms.
ANS: c

Weight-bearing stimulates osteoblastic activity and thus decreases the demineralization of bone
that develops with prolonged immobilization.

32. The wife of a client with severe cerebral edema inquires why the nurse checks the blood
glucose so often. The nurse’s most helpful response is
a. “The stress from the injury may have caused a transitory diabetes.”
b. “Because of altered metabolic processes sudden hyperglycemia can result.”
c. “A low blood sugar can lead to coma or seizure.”
d. “Hyperglycemia may increase the fluid collecting around the brain.”
ANS: c
Metabolic demands from the injury can lead to hypoglycemia, which might cause a coma or
seizure as well as deprive the brain of necessary glucose.

33. The nurse explains that brain edema, in contrast to brain swelling, is caused by an increase in
a. cerebral blood volume.
b. brain bulk from tumor growth.
c. ventricular pressure.
d. fluid content surrounding the brain.
ANS: d
Brain edema refers to an increase of fluid surrounding the brain.


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Black & Hawks: Medical-Surgical Nursing: Clinical Management for Positive

Outcomes, 7th Edition

Chapter 75: Management of Clients with Neurologic Trauma

DIF: Cognitive Level: Knowledge REF: Text Reference: 2191

DIF: Cognitive Level: Application REF: Text Reference: 2119

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2192

DIF: Cognitive Level: Application REF: Text Reference: 2201

DIF: Cognitive Level: Analysis REF: Text Reference: 2192

DIF: Cognitive Level: Comprehension REF: Text Reference: 2200

Elsevier items and derived items © 2005 by Elsevier Inc.

TOP: Nursing Process Step: Assessment

DIF: Cognitive Level: Application REF: Text Reference: 2206

DIF: Cognitive Level: Knowledge REF: Text Reference: 2192

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2201

DIF: Cognitive Level: Comprehension REF: Text Reference: 2189

DIF: Cognitive Level: Knowledge REF: Text Reference: 2211

Elsevier items and derived items © 2005 by Elsevier Inc.

d. alerted, because this indicates possible meningeal irritation.

DIF: Cognitive Level: Application REF: Text Reference: 2215

DIF: Cognitive Level: Analysis REF: Text Reference: 2215

DIF: Cognitive Level: Knowledge REF: Text Reference: 2215

Elsevier items and derived items © 2005 by Elsevier Inc.

b. his blood pressure and pulse rate.

DIF: Cognitive Level: Analysis REF: Text Reference: 2215

DIF: Cognitive Level: Application REF: Text Reference: 2216

DIF: Cognitive Level: Application REF: Text Reference: 2214

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2217

DIF: Cognitive Level: Comprehension REF: Text Reference: 2223

DIF: Cognitive Level: Application REF: Text Reference: 2227

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Knowledge REF: Text Reference: 2224

DIF: Cognitive Level: Application REF: Text Reference: 2215

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 2200

DIF: Cognitive Level: Comprehension REF: Text Reference: 2195

DIF: Cognitive Level: Application REF: Text Reference: 2224

Elsevier items and derived items © 2005 by Elsevier Inc.

DIF: Cognitive Level: Application REF: Text Reference: 2226

DIF: Cognitive Level: Application REF: Text Reference: 2195

DIF: Cognitive Level: Application REF: Text Reference: 2191

Elsevier items and derived items © 2005 by Elsevier Inc.

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