ALHS PREPARATION STUDY GUIDE-Caring for Clients with Head and Spinal Cord Trauma

ALHS-Caring for Clients with Head and Spinal Cord Trauma

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client

•  vomits.

  Explanation:

Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in a client with a concussion is an expected abnormal observation. However, a severe headache, weakness of one side of the body, and difficulty in waking the client should be reported or treated immediately.

Which stimulus is known to trigger an episode of autonomic dysreflexia in the client who has suffered a spinal cord injury?

•  Placing a blanket over the client

  Explanation:

An object on the skin or skin pressure may precipitate an autonomic dysreflexic episode. In general, constipation or fecal impaction triggers autonomic dysreflexia. When the client is observed to be demonstrating signs of autonomic dysreflexia, the nurse immediately places the client in a sitting position to lower blood pressure. The most common cause of autonomic dysreflexia is a distended bladder.

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be?

•  concussion

  Explanation:

A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. The force of the blow causes temporary neurologic impairment but no serious damage to cerebral tissue. There is generally complete recovery within a short time.