Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head?

The 36-year-old patient who has a history of migraine headaches.

The 56-year-old patient who is taking an antihypertensive medication.

The 76-year-old patient who is taking an anticoagulant.

The 16-year-old football player who suffered a concussion

Answer and Explanation

The Correct Answer is C

A. Migraine history does not increase the risk of bleeding or hematoma formation following head trauma.
B. Antihypertensive medications manage blood pressure but do not directly increase the risk of bleeding into the brain.
C. Older adults, especially those on anticoagulants, are at higher risk of developing subdural hematomas due to increased cerebral atrophy and impaired clotting, which makes even minor head trauma potentially life-threatening.
D. While concussions are concerning, a young, otherwise healthy individual is at lower risk of developing a subdural hematoma compared to an elderly patient on anticoagulants.

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Correct Answer is C

Explanation

A. Bladder distention is a common trigger of autonomic dysreflexia, but the immediate priority is to reduce blood pressure by positioning the patient.
B. Antihypertensive medication may be necessary, but nonpharmacologic interventions such as positioning and removing the triggering stimulus should be done first.
C. Placing the client in a high-Fowler’s position is the first action to lower blood pressure by promoting venous pooling in the lower extremities, thereby reducing cerebral blood pressure and minimizing the risk of stroke.
D. Heart rate monitoring is part of the assessment but does not take priority over immediately addressing the dangerously high blood pressure.

A. neurogenic shock B. malignant hyperthermia C. neuroleptic malignant syndrome D. tardive dyskinesia

Correct Answer is A

Explanation

A. Neurogenic shock is a common complication of spinal cord injuries above T6, including T4, due to disruption of sympathetic pathways causing hypotension, bradycardia, and vasodilation.
B. Malignant hyperthermia is a rare genetic reaction to certain anesthetics, unrelated to spinal cord injury.
C. Neuroleptic malignant syndrome is a reaction to antipsychotic drugs, not related to spinal cord injury.
D. Tardive dyskinesia is a side effect of long-term antipsychotic use, unrelated to spinal cord injury.

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Which patient is the nurse most concerned with developing a subdural hematoma following an injury that resulted with a blow to the head?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has quadriplegia from a spinal cord injury and reports having a severe headache. The nurse obtains a blood pressure reading of 210/108 mm Hg and suspects the client is experiencing autonomic dysreflexia. Which of the following actions should the nurse take first?

Correct Answer is C

Explanation

The nurse in the emergency department is caring for a client who sustained a spinal cord injury at T4. The nurse should recognize that the client is at risk for developing

Correct Answer is A

Explanation

nurse is teaching a group of nursing students about spinal cord injuries in clients who are aged 65 years and older. Which of the following should the nurse identify as the most common cause of spinal cord injuries for this age group?

The nurse is caring for a client who has cerebral edema. Which of the following therapies should the nurse recognize as appropriate for the treatment of cerebral edema? (Select All that Apply.)

A client with a C3 spinal cord injury has a headache and nausea. The client's blood pressure is 170/100 mm Hg. How should the nurse respond initially?

The client has increased intracranial pressure with cerebral edema, and mannitol is administered. Which assessment should the nurse make to evaluate if a complication from the mannitol is occurring?

Which is a priority nonoperative treatment following a spinal cord injury?

Which intervention would the nurse identify as a priority when monitoring a patient recovering from a craniotomy?

Which term would the nurse use to document a patient who is comatose from a head injury and displays flexion of the arms, wrists, and fingers, as well as adduction of the upper extremities?

A nurse is preparing a client with a possible cervical spine injury for a prescribed CT scan of the head and neck after the client sustained a fall down a stairwell. Which intervention by the nurse is the most important?