ATI Dynamic Quiz Head Injury
A nurse in the ED is caring for a group of clients who all have an odor of alcohol on their breath and multiple injuries to the head and extremities. Which of the following clients should the nurse assess first? A. A client who is difficult to arouse and is unable to respond to questions. B. A client who has slurred speech and exhibits anger C. A client who reports nausea and vomiting. D. A client who is uncooperative and has uncoordinated movements.
A. A client who is difficult to arouse and is unable to respond to questions. Rationale: A client who is difficult to arouse and is unable to respond to questions could have a decreased level of consciousness due to an alcohol intoxication level of 401/800mg/dL or traumatic brain injury. The greatest risk to this client is the neurological sequelae of head trauma or death due to severe alcohol intoxication. Incorrect Answers: speech impairment and mood changes are common findings in alcohol intoxication. the nurse should intervene for this client but assess another client first. Nausea and vomiting are common findings in alcohol intoxication. the nurse should intervene for this client but assess another client first. Reduced coordination and mood and behavioral changes are common with alcohol intoxication. the nurse should intervene for this client but assess another client first.
A nurse is caring for a client who has a traumatic brain injury and assumes a decerebrate posture in response to noxious stimuli. Which of the following reactions should the nurse anticipate when drawing a blood sample? A. the client rigidly extends his arms B. The client internally flexes his wrists. C. The client curls into a fetal position. D. The client internally rotates his legs.
A. The client rigidly extends his arms. Rationale: a client who exhibits a decerebrate posture rigidly extends and pronates the 4 extremities and externally rotates the wrists. Decerebrate posturing indicates a severe brain stem injury and late neurological decline. Incorrect Answers: a client who exhibits decorticate posturing internally flexes the wrists and arms and extends and plantar-flexes the legs. A fetal position is not a manifestation of a decerebrate posture. A client who exhibits decorticate posturing flexes the arms with internal rotation of the forearms and extends and plantar-flexes the legs.
A nurse is assessing a client with a closed head injury who has received mannitol for manifestations of ICP. Which of the following findings indicates that the medication is having a therapeutic effect? A. The client's serum osmolarity is 310 mOsm/L B. The client's pupils are dilated C. The client's heart rate is 56/min. D. The client is restless
A. The client's serum osmolarity is 310 mOsm/L Rationale: Mannitol is an osmotic diuretic used to reduce cerebral edema by drawing water out of the brain tissue. A serum osmolarity of 310 mOsm/L is desired. A decrease in cerebral edema should result in a decrease in ICP. Incorrect answers: dilated pupils, pinpoint pupils and asymmetrical pupils are manifestations of ICP. Bradycardia is a manifestation of increased ICP. Restlessness and behavioral changes are manifestations of increased ICP.
A nurse is assessing a client who sustained a recent head injury. Which of the following findings should the nurse recognize as a manifestation of increased intracranial pressure? A. widened pulse pressure B. Tachycardia C. Periorbital edema D. Decreased urine output
A. widened pulse pressure. Rationale: a widening of the pulse pressure (i.e. the difference b/w systolic and diastolic pressure) is a manifestation of increased intracranial pressure. Other manifestations include pupil changes, change in the LOC, and N/V. Incorrect answers: Tachycardia can be a manifestation of hypovolemia; however, bradycardia is a manifestation of increased intracranial pressure. Periorbital edema can occur following eye trauma or a craniotomy, however, it is not a manifestation of increased intracranial pressure. A decrease in urine output can be a manifestation of hypovolemia, however, it is not a manifestation of increased intracranial pressure.
A nurse is assessing a client who is unconscious. The client has a rhythmical breathing pattern of rapid deep respirations followed by rapid shallow respirations, alternating with periods of apnea. The nurse should document that the client is experiencing which of the following types of respirations? A. Orthopnea B. Cheyne-Stokes C. Paradoxical D. Kussmal
B. Cheyne-Stokes Rationale: Cheyne-Stokes respirations is a breathing pattern of deep to shallow breaths followed by periods of apnea. These respirations can be the result of a drug overdose or increased intracranial pressure and can precede death. Incorrect answers: a client who has orthopnea experiences SOB when in a supine position and is able to breathe easily when sitting upright. Paradoxical respirations (a flail chest) is a pattern of breathing in which the chest wall contracts during inspiration and expands during expiration. This can occur in a client who has sustained rib fractures. Kussmaul respirations are a deep, rapid respiratory pattern of hyperventilation that can occur in a client who has DKA.
A nurse in an ED is assessing a client who sustained a fall off a roof. Which of the following findings should the nurse identify as an indication of a basilar skull fracture? A. Depressed fracture of the forehead. B. Clear fluid coming from the nares C. Motor loss on one side of the body. D. Bleeding from the top of the scalp.
B. Clear fluid coming from the nares. Rationale: cerebrospinal fluid manifests as a clear fluid coming from the nares or ears, indicating a basilar skull fracture. Incorrect answers: Although a client who has a depressed fracture of the forehead might also have additional head trauma, this finding does not indicate a basilar skull fracture, which occurs at the base of the skull. Motor loss on one side of the body is an indication of an injury to the cerebral hemisphere. The motor dysfunction will be contralateral to the site of, which mean on the opposite side of, the injury, similar to the results of a stroke. Loss of motor function can also be an indication that injury has occurred to the spinal cord. Although the client who has bleeding from the scalp might also have additional head trauma, this finding does not indicate a basilar skull fracture.
A nurse is caring for a client who experienced a traumatic brain injury. Which of the following findings indicates the client is experiencing increased intracranial pressure? A. Battle's sign B. Periorbital edema C. Dilated pupils D. Halo sign
C. Dilated pupils Rationale: Dilated pupils can indicate that ICP is increasing. This finding should be reported to the provider immediately. Incorrect answers: Battle's sign is bruising behind the ears and jaw that can occur from trauma of a skull fracture. It does not indicate increased ICP. Periorbital edema is a result of facial trauma. It does not indicate increased ICP. A halo sign is a clear or yellow ring surrounding a spot of fluid or blood from the nose or ear. The ring indicates leakage of cerebral spinal fluid that can occur with a skull fracture. It does not indicate increased ICP
A nurse is assessing a client who has increased intracranial pressure and has received IV mannitol. Which of the following findings indicates a therapeutic effect of this medication? A. decreased blood glucose B. decreased bronchospasms C. increased urine output D. increased temp
C. Increased urine output. Rationale: Mannitol is an osmotic diuretic used to reduce ICP by immobilizing intracranial fluid and inhibiting the reabsorption of water and electrolytes in the kidneys. Increased urine output and decreased intracranial pressure are therapeutic effects of this med. Incorrect answers: A decrease in blood glucose is not a therapeutic effect of mannitol. The nurse should monitor the client for hyperkalemia and hypokalemia. Decrease in bronchospasms is not a therapeutic effect of mannitol. The nurse should monitor the client for pulmonary edema. An increase in temp is not a therapeutic effect of mannitol. The nurse should monitor the client for renal failure.
A nurse is assessing a client who was admitted to the facility for observation following a closed head injury. Which of the following is the priority assessment the nurse should perform to determine a change in the client's neurological status? A. Vital signs B. Body posture C. Level of consciousness D. Examination of pupils
C. Level of consciousness. Rationale: Priority assess is level of consciousness. A change in the client's level of consciousness can be the first indication of a change in neurologic status. Incorrect answers: vital signs can indicate increasing intracranial pressure and pressure on the hypothalamus. Changes in the client's vital signs such as bradycardia and a widening pulse pressure are later findings that indicate a change in neurological status; therefore there is another assessment that is the priority. Posturing is seen when cortical control over motor function is lost. Abnormal posturing (e.g., decerebrate or decorticate posturing) are later findings that indicate a change in the client's neurological status; therefore there is another assessment that is the priority. A change in pupils (e.g., dilated or fixed) can indicate increasing intracranial pressure or discrete areas of brain ischemia. A change in the client's pupils is a later finding that can indicate a change in neurological status; therefore there is another assessment that is the priority.
An ED room nurse is assessing a client who has a new traumatic brain injury. The nurse observes extension of the client's arms and legs, pronation of the arms, and plantar flexion of the feet. Which of the following actions is the nurse's priority? A. Monitor urinary output B. Administer an osmotic diuretic C. Provide supplemental oxygen D. Initiate seizure precautions
C. Provide supplemental oxygen Rationale: The first action the nurse should take when using the ABC's approach to client care is to provide supplemental oxygen. The client might require an artificial airway and mechanical vent because these findings indicate decerebrate positioning, which is associated with brainstem injury and can lead to brain herniation and death. Incorrect answers: The nurse should insert an indwelling urinary catheter to monitor the client's urinary output and fluid balance, however, there is another action the nurse should take first. The nurse should administer an osmotic diuretic if prescribed to decrease cerebral edema; however, there is another action the nurse should take first. The nurse should initiate seizure precautions to protect the client from injury; however, there is another action the nurse should take first.
A nurse is assessing a client who recently experienced a head injury. Which of the following findings should the nurse identify as an indication of short-term memory impairment? A. inability to remember current age. B. inability to count backward C. Inability to locate eyeglasses D. inability to recall names of family members
C. inability to locate eyeglasses. Rationale: short-term memory loss is manifested by an inability to recall events or actions that just occurred, such as where the client recently placed her eyeglasses. Incorrect answers: The inability to remember one's current age indicates an orientation deficit, not a short-term memory impairment. The inability to count backward indicates an attention span deficit, not short-term memory impairment. The inability to recall family members' names indicates an orientation deficit and possible long-term memory loss, not short-term memory impairment.
A nurse is caring for a client who has a closed traumatic brain injury and is experiencing increased ICP. This increase in ICP is due to which of the following? A. decreased cerebral perfusion. B. leakage of cerebral spinal fluid. C. rigid skull containing cranial contents D. brain herniated into the brainstem
C. rigid skull containing cranial contents. Rationale: the nurse should identify that the client's rigid skull prevents expansion. An increase in edema and bleeding from the head injury against the rigid skull results in an increase in ICP. Incorrect answers: A decrease in cerebral perfusion is a result of increasing ICP, not the cause. This leads to brain tissue ischemia and edema, which can cause death if untreated. The leakage of cerebral spinal fluid occurs with a basilar skull fracture, which is an open traumatic injury rather than a closed traumatic injury. Brain herniation can occur as a result of untreated increased intracranial pressure and can lead to death. It is not a cause of increased intracranial pressure.
A nurse is preparing a client for an EEG. When the client asks the nurse what this test does, which of the following responses should the nurse provide? A. An EEG measures the electrical signals to your brain from hearing, sight, and touch. B. An EEG measures the electrical activity in your muscles. C. An EEG identifies the magnetic fields produced by electrical activity in your brain. D. An EEG records the electrical activity of your brain cells.
D. An EEG records the electrical activity of your brain cells. Rationale: An EEG measures brain waves via multiple electrodes the tech will attach to the scalp. An EEG provides info the provider can use to identify various problems, including seizure disorders, sleep disorders, inflammation, bleeding and migraine headaches. Incorrect answers: Evoked potentials measure the electric signals to the brain from hearing, sight and touch. Electromyography measures the electrical activity of the muscles. Magnetoencephalography measures the magnetic fields produced by electrical activity in the brain.
A nurse is triaging clients during a mass casualty event. Which of the following labels should the nurse assign to a client who has a head injury with fixed, dilated pupils? A. Red tag B. Yellow tag C. Green tag D. Black tag
D. Black tag Rationale: The nurse should assign a black tag, or a class IV label, to clients who are not expected to live and will be allowed to die naturally. Dilated pupils that are fixed or nonreactive to light are poor prognostic sign and indicate severely increased intracranial pressure. In a mass casualty situation, the overall goal is to provide lifesaving treatment to the greater number of people possible. Incorrect answers: The nurse should assign a red tag to clients who have life-threatening injuries but a high possibility of survival once they are stabilized. yellow tag-to clients who have major injuries that are not yet life-threatening Green tag-minor injuries that are not life-threatening and do not need immediate attention.
A nurse in the ED has assessed a client's airway, breathing, and circulation (ABC) following a head injury from a fall at work. Which of the following actions is the priority for the nurse to perform next? A. Question the client's coworkers about the mechanism of the injury. B. Check the patient's pupils for equality and reaction to light C. measure the client's alertness using the Glasgow Coma Scale D. Immobilize the client's cervical spine.
D. Immobilize the client's cervical spine. Rationale: The greatest risk to this client is an injury from a cervical spine dislocation and spinal cord compression following a traumatic head injury. Therefore, the priority action the nurse should take after assessing the client's ABCs is immobilizing the client's neck with a cervical collar. A Client who has head trauma might also have damage to the cervical spine. This is an essential component of the initial stabilization of a client who has a head injury. Incorrect Answers: The nurse should question the client's coworkers about the mechanism of injury, which can yield info that will aid the treatment of the client's injury. However, another action is the nurse's priority. The nurse should check the client's pupils and reaction to light to help determine if the client has increased intracranial pressure from a cerebral hemorrhage. However, another action is the nurse's priority. The nurse should measure alertness using the GCS to determine the client's level of consciousness. However, another action is the nurse's priority.
