Nursing Care: Head Injury
For each evaluation goal, click to specify if the expected outcome has been met or not met.
not met met met met
The nurse is caring for a client who experienced a head injury during a motor vehicle crash. Review the client's electronic health record (EHR). In the 0045 entry of the Nurse's Notes, which assessment findings require immediate action by the nurse? Select that all apply.
now 6 190/50 P: 55 dilated to 6mm and fixed
The nurse is caring for a client who experienced a head injury during a motor vehicle crash. Review the client's electronic health record (EHR). What is the client's neurological status? Select the assessment items needed to calculate a Glasgow coma score and select the correct score in each column based on the information given.
opens his eye spontaneously not verbally responding flexes in response to pain GCS: 4, 1, 3
After trauma to the head, bruising behind the ears, otherwise known as Battle's sign, suggests which type of skull fracture?
Basilar
Which statement best describes a concussion?
Injury causing a sudden temporary disruption in neural activity
Which injury is the most likely cause of elevated intracranial pressure?
Cerebral contusion
A client is being evaluated in the emergency department after falling from a bicycle and hitting their head. Which assessment findings require immediate action by the nurse? Select all that apply.
Crescent shaped bruising behind both ears Drainage from nose positive for Halo sign
Based on the chart information available, what are the top three highest risks to the client at this time?
Decreased intracranial adaptive capacity Acute confusion Ineffective tissue perfusion
Which nursing actions will reduce intracranial pressure? Select all that apply.
Drain 5 cc per hour from the ventriculostomy tube. Elevate the head of the bed to 30 degrees. Administer prescribed hydralazine 10 mg intravenous (IV) now. Administer prescribed mannitol 25 g intravenous (IV) now.
A client was hit in the head with a baseball. At the scene, they lost consciousness for a few minutes, then woke up and were able to talk without problems. Over the course of the next hour, the client became drowsy and less responsive to questions. They vomited once and reported a headache. Based on the symptoms, which head injury is the most likely?
Epidural hematoma
A client was in a motor vehicle crash and their head hit the steering wheel. Which assessment questions will get the most accurate information about the head injury? Select all that apply.
How fast was the vehicle going? Did the airbags deploy? Were the seatbelts being worn? Which part of the steering wheel did the head hit? Was there a loss of consciousness?
The nurse is caring for a client with a head injury. For each assessment finding, indicate if the client's condition has improved or declined.
Improved The temperature is down to 98.2 °F (36.8 °C). The Glasgow coma score has increased to 12. Oxygen saturation increased to 97% on 4 liters of oxygen by nasal cannula. Albumin has increased to 3.5 mg/dL. Declined Cerebral perfusion pressure has decreased to 40 mmHg. A computed tomography (CT) scan shows increased cerebral edema. Intracranial pressure has increased to 25 mmHg.
For each potential nursing action, click to specify if the intervention is indicated, nonessential, or contraindicated for the care of the client. Select only one answer for each row.
Indicated Elevate the head of the bed Administer prescribed antihypertensive Administer prescribed corticosteroid Nonessential Turn and reposition the client every hour Contraindicated Place the bed in a Trendelenburg position Turn the head side to side every hour
Which injury causes a coup-contrecoup injury?
Rapid deceleration with cerebral contusion
For each client finding, indicate if it is consistent with a skull fracture, cerebral hemorrhage, or concussion.
Skull Fracture Positive halo sign Battle sign Cerebral Hemorrhage Widening pulse pressure Non-reactive pupillary response Glasgow Coma Scale of 8 Concussion Brief loss of consciousness
Complete the following sentences with the correct choices. In a client with a head injury, cerebral edema occurs _________ as inflammatory response causes an increase in _______ pressure. As the body's compensatory mechanisms fail, pressure increases more _______, leading to ________.
slowly intracranial rapidly herniation
