Traumatic Brain Injuries

Which intervention would the nurse include in the plan of care for a mechanically ventilated patient with a traumatic brain injury (TBI)? Cluster nursing interventions. Limit suctioning to four passes per episode. Maintain PaCO2 level at 45 mm Hg or higher. Use cooling blankets to maintain temperature at 37℃.

Use cooling blankets to maintain temperature at 37℃. Cerebral oxygen consumption is increased during periods of increased body temperature. As a result, the goal is to achieve normothermia (36 to 37℃).

Label the types of intracranial hemorrhages. Epidural hematoma Intracerebral hematoma Subdural hematoma

A - (top image; hematoma on left) epidural hematoma B - (middle image; hematoma on right) subdural hematoma C - (bottom image; hematoma in middle of brain) intracerebral hematoma

Which clinical manifestation would the nurse expect in a patient with a concussion? Select all that apply. One, some, or all responses may be correct. Disorientation Nausea Dizziness Retrograde amnesia Irritability

Disorientation Disorientation is a common clinical manifestation of a concussion. Nausea A common clinical manifestation of a concussion is nausea. Dizziness Dizziness is a common clinical manifestation of a concussion. Retrograde amnesia Concussions sometimes cause a period of retrograde amnesia, which affects memories that were formed before the onset of amnesia. Irritability A common clinical manifestation of a concussion is irritability.

After a baseball bat injury to the right side of the head, the nurse notes a fixed and dilated right pupil. Based on the assessment findings, the nurse would prepare to implement interventions for which condition? Epidural hematoma Open skull fracture Subdural hematoma Concussion

Epidural hematoma A dilated and fixed pupil on the same side as the impact area is a hallmark of epidural hematoma.

Which assessment finding would indicate the need for intracranial pressure monitoring? GCS score of 5 Retrograde amnesia Increased irritability Nausea and vomiting

GCS score of 5 Intracranial pressure monitoring would be required for patients with a Glasgow Coma Scale (GCS) score of less than 8.

Which diagnostic test would the nurse anticipate for a patient that reports with Battle sign and raccoon eyes? Skull x-ray Head CT Cranial MRI Electrocardiogram

Head CT A computed tomography (CT) scan is typically required to visualize basilar skull fractures.

Cerebral edema from a traumatic brain injury would produce which intracranial change? Increased cerebral perfusion Decreased intracranial pressure Decreased permeability of the blood-brain barrier Increased tissue hypoxia

Increased tissue hypoxia Cerebral edema impairs perfusion, increasing tissue hypoxia.

Which medication would the nurse administer to a patient with an intracranial pressure (ICP) reading of 45 mm Hg? Mannitol Hypotonic saline Furosemide Lactated Ringer

Mannitol Mannitol is used to pull fluid from brain parenchyma and decrease ICP.

The nurse would maintain a systolic blood pressure (SBP) greater than 110 mm Hg in a patient with traumatic brain injury (TBI) who is which age? Select all that apply. One, some, or all responses may be correct. 16 years old 42 years old 57 years old 65 years old 84 years old

16 years old TBI guidelines currently recommend SBP be maintained greater than 110 mm Hg for patients 15 to 49 years old. 42 years old TBI guidelines currently recommend SBP be maintained greater than 110 mm Hg for patients 15 to 49 years old. 84 years old TBI guidelines currently recommend SBP be maintained greater than 110 mm Hg for patients over age 70.

Which patient would be most at risk for mortality related to traumatic brain injury (TBI)? 16-year-old with an accidental gunshot injury to the face 22-year-old who fell off a ladder 41-year-old who was in a motor vehicle accident 67-year-old who fell down a flight of steps

67-year-old who fell down a flight of steps Falls are a leading cause of TBI, and adults over age 65 are at highest risk for TBI-related mortality.

Which condition is associated with secondary injury experienced after a traumatic brain injury (TBI)? Hypoxia Contusion Laceration Hemorrhage

Hypoxia Hypoxia and hypotension are the leading causes of secondary injury in patients with a TBI.

To prevent secondary injury after a traumatic brain injury, the nurse would intervene if which assessment finding was noted? Select all that apply. One, some, or all responses may be correct. Intracranial pressure 30 mm Hg Mean arterial pressure 50 mm Hg Cerebral perfusion pressure 40 mm Hg Intracranial pressure 15 mm Hg Mean arterial pressure 105 mm Hg

Intracranial pressure 30 mm Hg The nurse would intervene for increased intracranial pressure (ICP). Normal ICP values are less than 10 to 15 mm Hg for adults. Mean arterial pressure 50 mm Hg The nurse would intervene for decreased mean arterial pressure (MAP); normal MAP is between 70 and 100 mm Hg. Cerebral perfusion pressure 40 mm Hg The nurse would intervene for decreased cerebral perfusion pressure (CPP). Normal CPP lies between 60 and 80 mm Hg.

When caring for a patient with an epidural hematoma, which assessment finding would indicate the need for an immediate craniotomy? Increased level of consciousness Inadequate oxygenation Increased respiratory rate Midline shift on a CT scan

Midline shift on a CT scan If a lesion identified on a computed tomography (CT) scan is causing a shift of intracranial contents or increasing ICP, surgical intervention is necessary.

How would the nurse interpret a patient's assessment findings that include a 4-minute loss of consciousness (LOC) and a score of 15 on the Glasgow Coma Scale (GCS)? No evidence of brain injury Mild traumatic brain injury Moderate traumatic brain injury Severe traumatic brain injury

Mild traumatic brain injury Mild TBI is described as a GCS score of 13 to 15 with LOC that lasts up to 15 minutes.

Which interpretation would the nurse make of a patient's assessment findings that include a 4-minute loss of consciousness (LOC) and a score of 15 on the Glasgow Coma Scale (GCS)? No evidence of brain injury Mild traumatic brain injury Moderate traumatic brain injury Severe traumatic brain injury

Mild traumatic brain injury Mild traumatic brain injury (TBI) is described as a GCS score of 13 to 15 with LOC that lasts up to 15 minutes. Patients with mild TBI are seen in the emergency department and often discharged home with a family member who is instructed to evaluate the patient routinely and to bring the patient back to the hospital if any further neurologic symptoms appear.

The nurse would immediately notify the surgical team for a patient with which traumatic brain injury? Open skull fracture Basilar skull fracture Focal contusion Concussion

Open skull fracture Open skull fractures require surgical intervention to remove bony fragments and close the dura mater.

Which intervention would the nurse incorporate for a patient with a Glasgow Coma Scale (GCS) score of 5 after resuscitation? Select all that apply. One, some, or all responses may be correct. Perform serial CT scans. Prepare the patient for critical care admission. Implement mechanical ventilation. Administer blood replacement products. Educate the family members on discharge procedures.

Perform serial CT scans. A GCS score of 8 or less after resuscitation indicates severe traumatic brain injury (TBI). Serial computed tomography (CT) scans would be performed to rule out evidence of ongoing bleeding. Prepare the patient for critical care admission. Severe TBI is defined as a GCS score of 8 or less after resuscitation. The patient would be admitted to the critical care unit for continuous neurologic assessment. Implement mechanical ventilation. A GCS score of 8 or less after resuscitation indicates severe TBI. The patient would likely require mechanical ventilation.

Which assessment finding would be most concerning in a patient admitted with traumatic brain injury (TBI)? Respiratory rate of 6 breaths/min SpO2 of 94% Temperature of 99.4℉ Blood pressure of 136/94 mm Hg

Respiratory rate of 6 breaths/min Hypercapnia is usually caused by hypoventilation in an unconscious patient and worsens TBI, causing secondary injury.