Correct answer—C. Rationales: The temporal lobe contains the auditory association area. If the area is damaged in the dominant hemisphere, the client hears words but doesn’t know their meaning. Damage to the parietal lobe affects the client’s ability to identify special relationships with the environment. When damaged, the occipital lobe affects visual associations—the client can visualize objects but can’t identify them. The frontal lobe acts as a storage area for memory.

Nursing process step: Analysis

Correct answer—D. Rationales: Evaluation of brain stem function can be done in an unconscious client by testing the oculo-cephalic reflex. When the client’s head is rotated, the eyes should move in a direction opposite to the head movement. Brain-stem damage is indicated if the eyes move in the same direction as head movement. Evaluation of this reflex is contraindicated in a client with suspected cervical spine injury. CN I is the olfactory nerve; damage to this nerve results in the inability to identify odors. The fovea is the center of the retina’s macula, the area of greatest visual acuity.

Nursing process step: Assessment

Correct answer-C. Rationales: The facial nerve, CN VII, controls facial expression and taste in the anterior two-thirds of the tongue. CN II, the optic nerve, allows the client to blink and perceive light. CN V, the trigeminal nerve, controls jaw movement and facial sensation. CN XII, the hypoglossal nerve, controls tongue movement.

Nursing process step: Assessment

Correct answer-B. Rationales: Immobilization of the head and neck reduces the risk of further damage to the cervical spine. All clients with suspected head and neck trauma should be immobilized until all seven cervical vertebrae are cleared by X-ray visualization. A complete head-to-toe assessment (secondary survey) should be performed after airway, breathing, and circulation are assessed, the cervical spine is immobilized, and the client is evaluated for potential life-threatening injuries (primary survey). Administering opioid analgesics to a client with altered mental status or head injuries isn’t a primary intervention because opioids can increase respiratory depression and hypotension in clients with head injury. Obtaining a specimen for blood alcohol level helps to determine whether the amount of alcohol the client has consumed corresponds with the level of consciousness. Although this is useful information, it isn’t a primary intervention.

Nursing process step: Intervention

Correct answer-C. Rationales: The client is given 5 points for purposeful movement to pain (motor), 3 points for inappropriate words (verbal), and 2 points for eye opening in response to painful stimuli. The total score is 10.

Nursing process step: Evaluation

Correct answer-B. Rationales: A client with possible spinal cord injury typically complains of numbness and tingling in the extremities or an inability to detect sensation. A client with injury to the spinal cord commonly becomes bradycardic and hypotensive. Cloudy CSF is associated with bacterial infections such as meningitis. Exophthalmos is an abnormal protrusion of the eyeball. It’s associated with orbital tumors, thyroid disorders, and orbital cellulitis.

Nursing process step: Assessment

Correct answer-B. Rationales: An ovoid pupil is the midpoint between a normally round pupil and a fully dilated and fixed pupil and is a sign of increased intracranial pressure. Traumatic orbital injury results in a jagged-appearing pupil. A keyhole-shaped pupil is common in clients who have had an iridectomy as part of cataract surgery. Pontine hemorrhage causes the pupil to be pinpoint.

Nursing process step: Assessment

Correct answer-C. Rationales: The Modified Ramsey Score for Sedation measures the level of sedation achieved with pharmacologic agents. A Ramsey score of 5 suggests that the client responds only to noxious stimuli. A client who’s anxious, agitated, or restless has a Ramsey score of 1. A client who’s cooperative, tranquil, and oriented has a score of 2. A client who responds to voice and verbal commands has a Ramsey score of 3. A client who responds to gentle shaking scores a 4. A client who shows no response to noxious stimuli is considered a 6 on the scale.

Nursing process step: Evaluation

Correct answer—C. Rationales: Succinylcholine is a neuromuscular blocking agent that can increase intracranial pressure (ICP) in a client with head injuries. Administering 1 mg/kg of lidocaine provides ICP control. Atropine is the premedication of choice for children receiving succinylcholine because it decreases the bradycardia that occurs with succinylcholine administration. Ketamine and meperidine are contraindicated in a client with head injuries because they increase ICP.

Nursing process step: Intervention

Correct answer-C. Rationales: Normal ICP should be less than 10 mm Hg when measured at the foramen of Monro. Widening pulse pressure, hyperthermia, and Cheyne-Stokes respirations are signs of increased ICP. Kussmaul’s respirations are associated with diabetic ketoacidosis.

Nursing process step: Assessment

Correct answer-D. Rationales: Mannitol is an osmotic diuretic that decreases ICP. Suctioning the client’s airway should be minimized to prevent increased ICP. Meperidine should be used cautiously in a client with head injury or increased ICP; the drug’s respiratory depressant effects are considerably enhanced in these situations. A client with a head injury should have his head elevated 30 degrees to promote venous drainage. Placing a client in Trendelenburg’s position obstructs venous return from the brain and increases ICP.

Nursing process step: Intervention

Correct answer-D. Rationales: Paralysis is a late symptom of MS. The earliest clinical sign of MS may be vague, such as weakness, numbness, or tingling in limbs; visual blurring; or urinary changes. Motor symptoms initially present as weakness and then progress to paralysis. Diplopia (double vision) or scotoma (area of depressed vision in the visual field) may also present early in the disease.

Nursing process step: Assessment

Correct answer—A. Rationales: A subdural hematoma, occurring between the dura mater and the arachnoid layer of the meninges, is bleeding that causes direct pressure to the surface of the brain. Signs and symptoms appear within 48 hours (acute) and can be delayed as long as several months (chronic). Symptoms of an epidural hematoma include a history of momentary loss of consciousness followed by a lucid period after which the client’s mental status deteriorates rapidly due to the presence of bleeding from the middle meningeal artery. The clinical manifestations of a diffuse axonal injury are immediate and prolonged coma with decorticate or decerebrate posturing. Manifestations of postconcussion syndrome include headache, dizziness, irritability, poor judgment, and insomnia.

Nursing process step: Analysis

Correct answer—A. Rationales: The medulla controls the arterioles, the blood pressure, and the rate and depth of respirations. Severe injury to this area generally results in death. The medulla also controls yawning, coughing, vomiting, and hiccoughing. The frontal lobe of the cerebrum controls personality, judgment, thought, and logic. The diencephalon contains the thalamus, which is the sensory pathway between the spinal cord and the cortex of the brain. The hypothalamus regulates body temperature, heart rate, appetite, and sleep.

Nursing process step: Evaluation

Correct answer—A. Rationales: All the options listed are symptoms of a basilar skull fracture; however, Battle’s sign, a later manifestation, may not become evident until 12 to 24 hours after injury.

Nursing process step: Assessment

Correct answer—C. Rationales: An epidural hematoma results from blood collecting between the skull and the dura mater. A subdural hematoma is commonly caused by trauma or violent shaking and results in a collection of venous blood between the dura mater and the arachnoid mater. A subarachnoid hemorrhage is a collection of blood between the pia mater and the arachnoid membrane. A contusion is a bruise on the surface of the brain.

Nursing process step: Evaluation

Correct answer—C. Rationales: The child has classic signs of a traumatic head injury such as subarachnoid hemorrhage, which is caused by arterial disruption that leads to the collection of blood between the pia mater and the arachnoid membrane. This injury is frequently associated with child abuse. A client with a history of coagulation or hematologic disorders may present with ecchymoses, petechiae (in platelet disorders), or purpura. Meningitis is associated with lethargy, irritability, fever, seizures, and headache. Petechiae and purpura present in meningococcemia. When assessing any client, the history, psychological findings, and client’s appearance must also be considered to determine whether the signs and symptoms are consistent with the client history.

Nursing process step: Assessment

Correct answer-B. Rationales: Because the patient has circulation and airway intact as evidenced by speaking, the next priority is breathing. Administrating oxygen via a nonrebreather mask is a breathing intervention. After circulation, airway, and breathing have been addressed, the next focus would be stabilization and immobilization of the cervical spine. Based on the history of falling down stairs, the cervical spine immobilization must be maintained until fractures are ruled out by X-ray or computed tomography scan. Lorazepam is effective in controlling seizure activity and may be administered either I.M. or I.V. After completing the rapid primary assessment, an I.V. should be established to facilitate resuscitative and pharmacologic interventions.

Nursing process step: Intervention

Correct answer—A. Rationales: The normal heart rate for a 1-year-old child ranges from 90 to 120 beats/minute. Bradycardia is a sign of increasing intracranial pressure. Normally, respirations for a child in this age range from 20 to 30 breaths/minute. Capillary refill time less than or equal to 3 seconds is a normal finding. After age 2 or after the child is walking, a positive Babinski’s reflex is an abnormal finding.

Nursing process step: Assessment

Correct answer-A. Rationales: The head of the bed should be maintained at 30 degrees, and hyperextension, flexion, and rotation of the head should be avoided. A rotated position will prevent venous outflow via the jugular veins and contribute to increased ICP. Lowering the head of the bed would increase the pressure on the brain. Closing the stopcock on the ventriculostomy causes the ICP to rise because there’s no longer an outlet for CSF.

Nursing process step: Intervention

Correct answer-A. Rationales: A client with an injury at level C6 has quadriplegia with diaphragmatic breathing and gross arm movements. The client may also suffer from hypotension and an atonic bladder. An injury at level C2 results in total loss of respiratory function and movement from the shoulders down. Paraplegia with loss of portions of intercostal and abdominal muscles is indicative of injury at T1-L2. An injury below L2 results in mixed motor sensory loss and bowel and bladder dysfunction.

Nursing process step: Assessment

Correct answer-B. Rationales: When phenytoin is administered I.V., it shouldn’t be given faster than 50 mg/minute because doing so can depress the myocardium and lead to arrhythmias and cardiac arrest. Therapeutic blood levels should range from 10 to 20 mg/ml. Mixing phenytoin in any solution other than normal saline can cause the drug to precipitate into crystals. Phenytoin inhibits the action of cardiac glycosides and corticosteroids. It does, however, potentiate the actions of propranolol (Inderal), methotrexate (Mexate), and antihypertensives.

Nursing process step: Intervention

Correct answer—C. Rationales: Because of the slow absorption of phenytoin from the GI tract, daily drug routines can be easily adjusted when a dose is missed. One of the most common causes of seizures in a client taking phenytoin is discontinuation of the medication. The client also needs to be made aware of possible adverse effects of his medications. Phenytoin is metabolized in the liver, and both the inactive metabolites and unchanged drug are excreted in the urine. Because phenytoin has many hematopoietic adverse effects, blood work (including complete blood count, liver, and renal function studies) should be obtained on a regular basis. Serum levels should also be monitored because serum concentrations increase disproportionately to dosing regimens.

Nursing process step: Intervention

Correct answer-B. Rationales: Guillain-Barré syndrome is distinguished from other forms of polyneuritis by its acute onset and rapid progression. It’s classified as a neuritis because it causes demyelination of the spinal cord, peripheral nerves, root ganglia, and nerve roots. The disease manifests itself by sudden onset of lower-extremity weakness that rapidly progresses to the arms, trunk, and face. It primarily affects people between ages 30 and 50.

Nursing process step: Analysis

Correct answer-D. Rationales: Alopecia isn’t a manifestation of Parkinson’s disease. The symptom that typically characterizes this disease is a faint tremor that slowly progresses in intensity. As the client’s muscle tone becomes more rigid, the gait takes on a shuffling appearance. The client’s face is masklike, and his speech is slow and monotone. It’s common for the client to develop dysphagia and drooling. The client’s judgment becomes impaired even though actual intelligence remains unaffected.

Nursing process step: Assessment

Correct answer—A. Rationales: Pramipexole (Mirapex) is a dopamine agonist. It activates dopamine receptors, which mimic or copy the function of dopamine in the brain. The use of dopamine-blocking drugs has been linked to pharmacologically increased parkinsonism. Dopamine and acetylcholine are neurotransmitters that act on the input nuclei to the basal ganglia. When dopamine (an inhibitor) is reduced, acetylcholine (an excitatory neurotransmitter) becomes predominant and precipitates tremor.

Nursing process step: Intervention