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 ventilators 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 clients 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. c. Normal 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 d. Hematuria 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. Hes 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 clients 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? a. Aphasia b. Hemiparesis c. Paraplegia d. :-) Tetraplegia 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 clients 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 RATIONALE: 1. The nurse should first attempt nursing interventions, such as repositioning the client to avoid neck flexion, which increases venous return and lowers ICP. If nursing measures prove ineffective, notify the physician, who may prescribe mannitol, pentobarbital, or hyperventilation therapy. 2. Dilantin IV shouldnt be given at a rate exceeding 50 mg/minute. Rapid administration can depress the myocardium, causing arrhythmias. Therapeutic drug levels range from 10 to 20 mg/ml. Dilantin shouldnt be mixed in solution for administration. However, because its compatible with normal saline solution, it can be injected through an IV line containing normal saline. When given through an IV catheter hand, dilantin may cause purple glove syndrome. 3. Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific

gravity, increased serum osmolarity, and dehydration. Theres no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesnt need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present. 4. A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2. 5. Frequent swallowing after brain surgery may indicate fluid or blood leaking from the sinuses into the oropharynx. Blood or fluid draining from the ear may indicate a basilar skull fracture. 6. After hypophysectomy, or removal of the pituitary gland, the body cant synthesize ADH. Somatropin or growth hormone, not vasopressin is used to treat growth failure. SIADH results from excessive ADH secretion. Mannitol or corticosteroids are used to decrease cerebral edema. 7. All clients with a head injury are treated as if a cervical spine injury is present until x-rays confirm their absence. ROM would be contraindicated at this time. There is no indication that the client needs a chest x-ray. The airway doesnt need to be opened since the client appears alert and not in respiratory distress. In addition, the head-tilt chin-lift maneuver wouldnt be used until the cervical spine injury is ruled out. 8. Tetraplegia occurs as a result of cervical spine injuries. Paraplegia occurs as a result of injury to the thoracic cord and below. 9. After a spinal cord injury, ascending cord edema may cause a higher level of injury. The diaphragm is innervated at the level of C4, so assessment of adequate oxygenation and ventilation is necessary. Although the other options would be necessary at a later time, observation for respiratory failure is the priority. 10. Symptoms of neurogenic shock include hypotension, bradycardia, and warm, dry skin due to the loss of adrenergic stimulation below the level of the lesion. Hypertension, bradycardia, flushing, and sweating of the skin are seen with autonomic dysreflexia. Hemorrhagic shock presents with anxiety, tachycardia, and hypotension; this wouldnt be suspected without an injury. Pulmonary embolism presents with chest pain, hypotension, hypoxemia, tachycardia, and hemoptysis; this may be a later complication of spinal cord injury due to immobility.

JOHN RONALD A. DINO BSN 4A1 GROUP 3C