1. 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?
a. Reposition the client to avoid neck flexion
b. Administer 1 g Mannitol IV as ordered
c. Increase the ventilator’s respiratory rate to 20 breaths/minute
d. Administer 100mg of pentobarbital IV as ordered.
2. 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?
a. Therapeutic drug levels should be maintained between 20 to 30 mg/ml.
b. Rapid dilantin administration can cause cardiac arrhythmias.
c. Dilantin should be mixed in dextrose in water before administration.
d. Dilantin should be administered through an IV catheter in the client’s hand.
3. 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?
a. Evaluate urine specific gravity
b. Anticipate treatment for renal failure
c. Provide emollients to the skin to prevent breakdown
d. Slow down the IV fluids and notify the physician
4. When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result?
a. Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP).
b. Emergent; the client is poorly oxygenated.
d. Significant; the client has alveolar hypoventilation.
5. A client who had a transsphenoidal hypophysectomy should be watched carefully for hemorrhage, which may be shown by which of the following signs?
a. Bloody drainage from the ears
b. Frequent swallowing
c. Guaiac-positive stools
6. After a hypophysectomy, vasopressin is given IM for which of the following reasons?
a. To treat growth failure
b. To prevent syndrome of inappropriate antidiuretic hormone (SIADH)
c. To reduce cerebral edema and lower intracranial pressure
d. To replace antidiuretic hormone (ADH) normally secreted by the pituitary.
7. 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?
a. Assess full ROM to determine extent of injuries
b. Call for an immediate chest x-ray
c. Immobilize the client’s head and neck
d. Open the airway with the head-tilt chin-lift maneuver
8. A client with a C6 spinal injury would most likely have which of the following symptoms?
9. A 30-year-old was admitted to the progressive care unit with a C5 fracture from a motorcycle accident. Which of the following assessments would take priority?
a. Bladder distension
b. Neurological deficit
c. Pulse ox readings
d. The client’s feelings about the injury
10. While in the ER, a client with C8 tetraplegia develops a blood pressure of 80/40, pulse 48, and RR of 18. The nurse suspects which of the following conditions?
a. Autonomic dysreflexia
b. Hemorrhagic shock
c. Neurogenic shock
d. Pulmonary embolism
11. A client is admitted with a spinal cord injury at the level of T12. He has limited movement of his upper extremities. Which of the following medications would be used to control edema of the spinal cord?
a. Acetazolamide (Diamox)
b. Furosemide (Lasix)
c. Methylprednisolone (Solu-Medrol)
d. Sodium bicarbonate
12. 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?
a. Place the client flat in bed
b. Assess patency of the indwelling urinary catheter
c. Give one SL nitroglycerin tablet
d. Raise the head of the bed immediately to 90 degrees
13. A client with a cervical spine injury has Gardner-Wells tongs inserted for which of the following reasons?
a. To hasten wound healing
b. To immobilize the surgical spine
c. To prevent autonomic dysreflexia
d. To hold bony fragments of the skull together
14. Which of the following interventions describes an appropriate bladder program for a client in rehabilitation for spinal cord injury?
a. Insert an indwelling urinary catheter to straight drainage
b. Schedule intermittent catherization every 2 to 4 hours
c. Perform a straight catherization every 8 hours while awake
d. Perform Crede’s maneuver to the lower abdomen before the client voids.
15. 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?
a. Laceration of the middle meningeal artery
b. Rupture of the carotid artery
c. Thromboembolism from a carotid artery
d. Venous bleeding from the arachnoid space
16. 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. Position the client flat in bed
b. Check the fluid for dextrose with a dipstick
c. Suction the nose to maintain airway patency
d. Insert nasal and ear packing with sterile gauze
17. When discharging a client from the ER after a head trauma, the nurse teaches the guardian to observe for a lucid interval. Which of the following statements best described a lucid interval?
a. An interval when the client’s speech is garbled
b. An interval when the client is alert but can’t recall recent events
c. An interval when the client is oriented but then becomes somnolent
d. An interval when the client has a “warning” symptom, such as an odor or visual disturbance.
18. Which of the following clients on the rehab unit is most likely to develop autonomic dysreflexia?
a. A client with a brain injury
b. A client with a herniated nucleus pulposus
c. A client with a high cervical spine injury
d. A client with a stroke
19. Which of the following conditions indicates that spinal shock is resolving in a client with C7 quadriplegia?
a. Absence of pain sensation in chest
c. Spontaneous respirations
d. Urinary continence
20. A nurse assesses a client who has episodes of autonomic dysreflexia. Which of the following conditions can cause autonomic dysreflexia?
b. Lumbar spinal cord injury
c. Neurogenic shock
d. Noxious stimuli
21. During an episode of autonomic dysreflexia in which the client becomes hypertensive, the nurse should perform which of the following interventions?
a. Elevate the client’s legs
b. Put the client flat in bed
c. Put the client in the Trendelenburg’s position
d. Put the client in the high-Fowler’s position
22. 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?
a. Autonomic dysreflexia
c. Neurogenic shock
23. 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?
a. Absent corneal reflex
b. Decerebate posturing
c. Movement of only the right or left half of the body
d. The need for mechanical ventilation
24. A client with C7 quadriplegia is flushed and anxious and complains of a pounding headache. Which of the following symptoms would also be anticipated?
a. Decreased urine output or oliguria
b. Hypertension and bradycardia
c. Respiratory depression
d. Symptoms of shock
25. A 40-year-old paraplegic must perform intermittent catherization of the bladder. Which of the following instructions should be given?
a. “Clean the meatus from back to front.”
b. “Measure the quantity of urine.”
c. “Gently rotate the catheter during removal.”
d. “Clean the meatus with soap and water.”