Ch 19
A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated? 1. Maintain neutral body position. 2. Turn and reposition every 4 hours. 3. Apply antiembolism stockings. 4. Ensure oxygen saturation level of 92%.
1. Maintain neutral body position. 1. A neutral body position will help prevent contractures in that it avoids flexion. 2. The patient should be turned and repositioned every 2 hours to help prevent contractures. 3. Applying antiembolism stockings will prevent the immobility complication of deep vein thrombosis development and not prevent contractures. 4. The patient's oxygen saturation should be maintained at 92% or higher; however, this will not prevent the complication of contracture.
A patient is brought to the hospital after being found on the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient's airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse's secondary survey? Select all that apply. 1. "How did the injury occur?" 2. "What care was provided at the site of the injury?" 3. "Has anything like this ever happened before?" 4. Blood pressure measurement will occur. 5. A general systems assessment will occur.
1. "How did the injury occur?" 2. "What care was provided at the site of the injury?" 3. "Has anything like this ever happened before?" 5. A general systems assessment will occur. 1. The most obvious answer to this question is that the patient fell down the stairs, but this may be an incorrect assumption. The patient may have been injured in some other manner and it was a coincidence that it occurred at the bottom of a flight of stairs. Determining mechanism of injury is a part of the secondary survey. 2. The nurse should determine what care has already been provided. 3. Comorbid conditions or previous history is a part of the secondary survey. 4. Blood pressure measurement is part of the primary survey. 5. The general systems assessment is part of the secondary survey.
A patient being treated for increased intracranial pressure (ICP) from a traumatic brain injury demonstrates an increase in pressure with minimal care activity. What instruction should the nurse provide the nursing student assisting with care for this patient? 1. "We will let this patient rest between his bath and changing his linens." 2. "We are going to bathe this patient, get his linens changed, suction him, and do all of our other care early this morning, so he can get a long rest this afternoon." 3. "Be certain that we don't raise this patient's head above 10 degrees during his bath." 4. "You have to learn to suction patients with traumatic brain injury very quickly, taking no more than 30 seconds."
1. "We will let this patient rest between his bath and changing his linens." 1. When simple activities result in an increase in intracranial pressure, it is necessary to space care in such a way to allow the patient's ICP to recover between events. 2. Stacking care activities will be detrimental to this patient. 3. The head of the bed should be elevated to 30 degrees to reduce intracranial pressure without compromising cerebral perfusion pressure. 4. The patient should be suctioned for 10 to 15 seconds or less to reduce an increase in intracranial pressure caused by the suctioning.
A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC). The nurse participates in tier two interventions to reduce intracranial pressure (ICP) through which uses of this catheter? Select all that apply. 1. Assessing of color of the cerebral spinal fluid (CSF) 2. Assessing of the amount of cerebral spinal fluid 3. Instillation of hyperosmolar therapy via the catheter 4. Draining CSF 5. Directly monitoring the ICP
1. Assessing of color of the cerebral spinal fluid (CSF) 2. Assessing of the amount of cerebral spinal fluid 4. Draining CSF 5. Directly monitoring the ICP 1. By assessing the color of the cerebral spinal fluid, the nurse can identify variation from normal. These variations may indicate bleeding or infection that would increase ICP. 2. By using IVC measurements, the nurse can monitor amount of CSF. 3. Hyperosmolar therapy is not instilled via this catheter. 4. Therapeutic drainage of CSF via the IVC can reduce ICP. 5. Insertion of an IVC allows for direct measurement of the ICP.
A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions. The nurse would anticipate which tier three intervention? 1. High-dose barbiturate therapy 2. High-volume intravenous fluids 3. Hyperbaric oxygen therapy 4. Hyperosmolar therapy
1. High-dose barbiturate therapy 1. Medical intervention for the treatment of increased intracranial pressure refractory to all other medical interventions may include the use of high-dose barbiturates. This intervention induces a comatose state and significantly decreases cerebral oxygen requirements. 2. High-volume intravenous fluid administration would be more likely to increase intracranial pressure. 3. Hyperbaric oxygen therapy is not a treatment identified to help with refractory increased intracranial pressure. 4. Hyperosmolar therapy is used as a level two intervention, not to treat refractory increase in intracranial pressure.
The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? Select all that apply. 1. Preoxygenate the patient prior to suctioning. 2. Use very low vacuum pressure when suctioning the patient. 3. Limit suction passes to 10 to 15 seconds or less. 4. Suction when PaCO2 levels rise above 40 mm Hg. 5. Suction the patient before and after scheduled turns.
1. Preoxygenate the patient prior to suctioning. 3. Limit suction passes to 10 to 15 seconds or less. 1. To maintain adequate oxygenation during suctioning, preoxygenation is indicated. 2. Low vacuum pressure will not adequately remove secretions, making suctioning ineffective or necessary more often. This will not increase oxygenation. 3. For patients at risk for increased intracranial pressure (ICP), total suction time should be limited to no more than 10 to 15 seconds. 4. Increased PaCO2 level may or may not be associated with need to suction. Desired PaCO2 level is 35 to 45 mm Hg. 5. The patient should be suctioned as needed, but nursing activities should be spaced as much as possible. Routine suctioning both before and after scheduled turns is not likely to be necessary and would decrease oxygenation.
A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure (ICP). The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which priority patient problem is most likely present in this patient and will guide initial selection of nursing interventions? 1. Breathing dysfunction 2. Capacity for intracranial adaptation is decreased 3. Increased risk of paralysis 4. Increased likelihood of aspiration
2. Capacity for intracranial adaptation is decreased 1. There is no assessment information that indicates this patient's breathing pattern is altered. 2. Increased ICP is a result of decreased ability of the intracranial protective mechanisms to compensate for the increase in brain volume caused by the presence of a mass. 3. There is no information given that indicates the patient is paralyzed. 4. There is no current evidence that this patient is at risk for aspiration.
A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse's priority? 1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight. 2. Keep the patient safe and maintain the airway. 3. Lower the head of the bed. 4. Initiate a recording of the patient's cardiac rhythm.
2. Keep the patient safe and maintain the airway. 1. The first medication administered is more likely to be a benzodiazepine. Medication administration is not the highest priority. 2. Priorities for the care of a patient with a traumatic brain injury that begins to demonstrate seizure activity include keeping the patient safe and maintaining airway, breathing, and circulation. 3. Lowering the head of the bed may or may not be indicated and is not the priority intervention. 4. Seizure activity will interfere with an accurate recording of the patient's cardiac rhythm.
A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician? Select all that apply. 1. The patient is taking a sulfa drug for urinary tract infection. 2. The patient has a bluish discoloration behind his ear. 3. The patient's nose is running. 4. The patient's smile is crooked. 5. The patient's tongue is lacerated.
2. The patient has a bluish discoloration behind his ear. 3. The patient's nose is running. 4. The patient's smile is crooked. 1. Medication history is not the most important information during emergent assessment. 2. Mastoid ecchymosis or "Battle's sign" can indicate basilar skull fracture. This assessment requires immediate attention. 3. The fluid in the patient's nose may be cerebral spinal fluid, not mucous. This is an important assessment of basilar skull fracture. 4. Facial nerve paralysis may indicate basilar skull fracture. 5. Tongue laceration is important, but is not an emergent problem.
A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit. The nurse would anticipate which assessment findings? 1. The accident causing this injury occurred several weeks ago. 2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion. 3. There is dilation of the pupils for several hours post injury. 4. There is presence of coma that may last for an extended period of time.
2. There are symptoms that are similar to those demonstrated by a patient who sustained a concussion. 1. Mild diffuse axonal injury generally manifests quickly after the accident. Onset of symptoms weeks after injury is more likely seen in patients with chronic subdural hematoma. 2. Mild diffuse axonal injury may contribute to postconcussive syndrome experienced by many patients following a brain concussion. 3. Dilated pupils are not necessarily associated with any degree of diffuse axonal injury. 4. A long-term comatose state is seen in severe diffuse axonal injuries.
A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? 1. Culture the patient's urine. 2. Contact the primary healthcare provider. 3. Administer the prn antipyretic. 4. Have the patient cough and deep breathe more frequently.
3. Administer the prn antipyretic. 1. Urinary tract infection will cause increased temperature and this may be a necessary intervention. It is not, however, the primary intervention. 2. It is important to keep the primary healthcare provider apprised of the patient's condition, but this is not the primary intervention. 3. Hyperthermia will increase cerebral metabolic rates, which will increase cerebral oxygen demands. The patient with a temperature should be provided with antipyretics or other measures to cool the body and reduce the temperature. 4. Implementing pulmonary hygiene activities will not reduce the patient's body temperature.
A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient's plan of care? 1. Restrict fluids. 2. Restrict sodium. 3. Monitor intravenous normal saline administration. 4. Provide potassium chloride intravenous replacements.
3. Monitor intravenous normal saline administration. 1. The patient's fluids should not be restricted since this will exacerbate the hypovolemia characteristic of this disorder. 2. The patient should not be on a sodium restriction. 3. Cerebral salt wasting is a state of hypovolemia so the patient should be treated with salt replacement via intravenous saline and oral salt tablets. 4. Potassium replacements are not indicated in the treatment of this complication.
The admission orders for a patient with traumatic brain injury say to keep the patient's head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? Select all that apply. 1. The patient's head is supported on two pillows. 2. The head of the patient's bed is elevated to 20 degrees. 3. The patient's hips are flexed at less than 90 degrees. 4. The neck is in the patient's position of comfort, which is rotated to the left. 5. The patient is facing forward.
3. The patient's hips are flexed at less than 90 degrees. 5. The patient is facing forward. 1. Placing the head on two pillows flexes the neck, which violates the idea of a "neutral" position. 2. Typically, the head of the patient's bed should be elevated to 30 degrees. 3. Hip flexion of greater than 90 degrees should be avoided. 4. The neck should not be rotated. 5. Neutral positioning for the head and neck is a forward-facing position.
A patient comes into the emergency department with complaints of headache, lethargy, and vomiting. He reports being hit in the head by a batted baseball during a company picnic "about 6 weeks ago." The nurse would ask additional assessment questions regarding which condition? 1. Acute subdural hematoma 2. Subacute subdural hematoma 3. Epidural hematoma 4. Chronic subdural hematoma
4. Chronic subdural hematoma 1. An acute subdural hematoma occurs less than 48 hours from injury so this is an unlikely injury pattern. 2. Subacute subdural hematoma occurs 48 hours to 2 weeks from injury so this is an unlikely injury pattern. 3. With an epidural hematoma, there is a brief loss of consciousness immediately following the injury, followed by an episode of being alert and oriented, and then a loss of consciousness again. The patient did not describe a loss of consciousness. 4. There are three categories of subdural hematoma, based on time of onset of symptoms. Chronic hematoma develops more than 2 weeks from injury. Since the patient had a head injury a few weeks prior, the nurse would have highest concern regarding a chronic subdural hematoma.
A patient is admitted with a traumatic brain injury (TBI). The nurse would anticipate participating in interventions toward which immediate goal? 1. Reducing cerebral swelling 2. Confining inflammation to one area 3. Supporting absorption of debris from neuronal death 4. Limiting ischemic tissue injury
4. Limiting ischemic tissue injury 1. Cerebral swelling can cause secondary injury, but this is not the immediate goal. 2. Inflammation can cause secondary injury, but this is not the immediate goal when caring for someone with TBI. 3. Eventually the body will rid itself of debris from death of any cells, but this is not the immediate goal. 4. The first goal in treating traumatic brain injury is to limit the primary ischemic tissue injury by aggressive prevention and treatment of hypoxia and hypotension. If efforts to meet this goal are successful, cerebral swelling neuronal death and cerebral inflammation can be limited as well.
A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms. What is the priority when caring for this patient? 1. Electrolyte replacements 2. Maintaining adequate fluid volume 3. Supporting nutritional needs 4. Maintaining stable cerebral perfusion pressure
4. Maintaining stable cerebral perfusion pressure 1. Electrolyte management is important to patients with head injury but is not the intervention of highest priority. 2. Fluid volume management is important when caring for patients with brain injury, but is not the highest priority. 3. Support of nutritional needs is important for all patients, but is not the intervention of highest priority for patients with brain injury. 4. Since diffuse head injuries are not limited to a localized area, this makes them more difficult to detect and treat. Management in the acute care phase includes diligent and frequent neurological assessments and pain management. When moderate-to-severe injury is present, priority management includes interventions to lower intracranial pressure, increase cerebral perfusion pressure, and stabilize vital signs, which all contribute to an improved outcome.
A patient diagnosed with a traumatic brain injury is receiving mannitol. The nurse would collaborate with the prescriber regarding discontinuation of therapy if which finding occurs? 1. Intracranial pressure (ICP) decreases. 2. Serum sodium is 148 mEq/L. 3. Serum osmolality is 300 mOsm. 4. Osmotic gap is 12.
4. Osmotic gap is 12. 1. Mannitol is given to decrease ICP. 2. Therapy should be withheld if the serum sodium is above 160 mEq/L. 3. Therapy should be withheld if the serum osmolality is greater than 320 mOsm. 4. Therapy should be withheld if the osmotic gap is greater than 10.
The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago. What information should the nurse provide? 1. Symptoms of the concussion will continue for most of the patient's life. 2. The concussion might be healed; however, the patient will not recover from the symptoms. 3. Symptoms of the concussion will come and go depending on the patient's health status. 4. Symptoms of a concussion can last 3 months or more.
4. Symptoms of a concussion can last 3 months or more. 1. Symptoms of the concussion will not continue for most of the patient's life. 2. The patient will recover from the symptoms. 3. The symptoms of the concussion will not come and go depending on the patient's health status. 4. Postconcussion syndrome is a condition where concussion symptoms similar to those experienced on presentation to the emergency department (ED) persist for 3 months or more after initial injury. It has been found to affect between 15% and 25% of patients with concussion 1 year after the initial injury.
The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma. Which assessment finding would warrant immediate collaboration with the surgeon? 1. Urine output has dropped from 100 mL each hour to 60 mL per hour. 2. The patient's hand grasps are weak bilaterally. 3. Fine crackles can be auscultated in the lung bases bilaterally. 4. The pupil on the side of the injury has become fixed and dilated.
4. The pupil on the side of the injury has become fixed and dilated. Urine output of 60 mL per hour is considered normal and would not require emergency collaboration. If urine output continues to drop, increasing intravenous fluid administration rate may be considered. 2. Weak hand grasps bilaterally may or may not indicate a worsening neurological condition. Bilateral weakness is not as significant for emergent conditions as is unilateral weakness. 3. Fine crackles auscultated bilaterally in lung bases can be due to several conditions, such as immobility, and are not indicative of an emergent neurological condition. 4. Nursing care associated with epidural hematoma focuses on diligent neurological assessment. The nurse must look for sudden changes in level of consciousness and for the presence of a fixed and dilated pupil on the side of injury. These findings suggest bleeding has recurred and represents an emergent medical situation.
A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective? 1. Potassium level has decreased. 2. Blood pressure has decreased. 3. Serum sodium level is increased. 4. Urine output has decreased.
4. Urine output has decreased. 1. Potassium level assessment is not an essential indicator of success in the treatment of a patient with diabetes insipidus. 2. The large amount of fluid lost in diabetes insipidus causes hypotension. Continued decrease in blood pressure does not indicate that treatment is successful. 3. Continued elevation of serum sodium level would indicate that treatment is not effective. 4. Treatment for diabetes insipidus includes replacing intravascular volume and providing synthetic antidiuretic hormone. Evidence that a patient is improving would include a decrease in urine output with an increase in specific gravity.
