Exam 3- TBI/ ICP
The nurse is assessing a 10-year-old client's level of consciousness in the emergency department because the mother feels her child is disoriented and lethargic. Which questions would the nurse want to ask the parent in assessing possible increased intracranial pressure (IICP) as a cause of her confusion and lethargy? (Select all that apply.) "Has the child had strep throat recently?" "Could your child been ingesting any household products, drugs, or medications?" "Has your child ever had a shunt, brain hemorrhage, or brain surgery?" "Does your family have animals at home?" "Has your child had any recent head trauma, falls, or accidents that you're aware of?"
"Could your child been ingesting any household products, drugs, or medications?" "Has your child ever had a shunt, brain hemorrhage, or brain surgery?" "Has your child had any recent head trauma, falls, or accidents that you're aware of?" Rationale: Health history is important when assessing for altered levels of consciousness. Asking about recent or past head trauma, falls, accidents, shunting, brain hemorrhage, or cranial surgery is useful in discerning possible reasons for altered level of consciousness (LOC). Parents should be asked about intentional or accidental ingestion or exposure to drugs or other substances. There is no particular association between a recent strep throat infection and an altered level of consciousness, although other illnesses such as meningitis or viral syndromes might predispose the client to problems with intracranial regulation. Recent animal exposure usually is not related to altered levels of consciousness.
A client presents to the Emergency Department with a head injury received in a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the nurse do? Lower the head of the bed to 30 degrees. Turn up the client's IV. Prepare the client for intubation. Repeat the client's blood pressure reading.
Prepare the client for intubation. The client with a GCS lower than 9 will likely be intubated immediately.
The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/ symptoms would warrant transferring a resident to the emergency department? A 4cm area of bright red drainage on the dressing. A weak pulse, shallow respirations, and cool pale skin. Pupils that are equal, react to light, and accommodate. Complaints of a headache that results with medication
A weak pulse, shallow respirations, and cool pale skin. The signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.
The nurses caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. Maintain the head of the bed at 60° of elevation Administer stool softeners daily Ensure the pulse oximeter reading is higher than 93% Perform deep nasal suction every two hours Administer mild sedatives
Administer stool softeners daily Ensure the pulse oximeter reading is higher than 93% Administer mild sedatives Stool softeners are initiated to prevent the Valsalva maneuver, which increases intracranial pressure. Oxygen saturation higher than 93% insurers oxygenation of the brain tissues, decreasing oxygen levels increase cerebral edema. Mild sedatives will reduce the clients agitation, strong narcotics would not be administered because they decrease the clients level of consciousness. The head of the bed should be elevated no more than 30° to help decrease cerebral edema by gravity. Noxious stimuli, such as suctioning, increased intracranial pressure and should be avoided.
epidural hematoma (EDH)
EDH, a hematoma located between skull and dura, usually results from high-impact trauma to the temporal brain area, with rupture of the middle meningeal artery and rapidly accumulating intracranial hematoma/hemorrhage.
Intracranial hematoma
ICH, a hematoma that develops within the brain parenchyma, can occur with trauma but is also associated with uncontrolled hypertension or ruptured aneurysm.
The client diagnosed with a gunshot went to the head assumes decorticate posturing when the nurse supplies painful stimuli. Which assessment Data obtained three hours later when indicate the client is improving? Purposeless movement in response to painful stimuli. Flaccid paralysis in all four extremities. Decerebrate posturing when painful stimuli is applied Pupils that are 6mm in size and nonreactive on painful stimuli.
Purposeless movement in response to painful stimuli. Purposeless movement indicates that the clients cerebral edema is decreasing. The best motor response is purposeful movement, but purposeless movement indicates an improvement over decorticate posturing, Which, In turn, is an improvement over just a reprint posturing or flaccidity.
Subdural hematoma
located between the dura and arachnoid layer-usually results from rupture of a venous vessel and slower onset of symptoms than seen in EDH. There are three types of SDH, based on the time that symptoms develop: acute, subacute, and chronic.
A previously asymptomatic 84-year-old client presents with aphasia but is otherwise alert and responsive. The nurse would suspect that this client has which condition? A stroke in the left cerebral hemisphere Damage to the brainstem A stroke in the right cerebral hemisphere A lesion in the occipital lobe
Rationale: Aphasia, defective/absent language function, can occur as a result of a stroke in speech center of the brain located in the left cerebral hemisphere. An individual with damage to the brainstem would present with marked cognitive, motor, and sensory dysfunction. A client with a lesion in the occipital area of the brain would manifest problems with vision.
A client is made hypothermic as treatment for a severe traumatic brain injury. The nurse should monitor for which complications of this therapy? Select all that apply. Increased blood glucose Acidosis Atrial fibrillation Shivering Decreased urine output
Shivering Acidosis Atrial fibrillation Acidosis is a complication of hypothermia treatment. There is no indication to monitor for increased blood glucose as a result of this therapy. Decreased urine output is not a complication of this therapy.
The 29-year-old client he was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after three months and has cognitive deficits. Which goal would be most realistic for this client? The client will return to work within six months The client is able to focus and stay on task for 10 minutes The client will be able to dress self without assistance The client will regain bowel and bladder control
The client is able to focus and stay on task for 10 minutes Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning. Therefore, an appropriate goal would be for the client to stay on task for 10 minutes. The client is at risk for seizures and does not process information appropriately. Allowing him to return to his occupation. Vocational training maybe required. The client's ability to dress self addresses self-care problems not a cognitive problem. The clients ability to regain bowel and bladder control does not address cognitive deficits.
A physician order for additional mannitol (Osmitrol) has been written for a client with increased ICP. Which assessment finding would cause the nurse to question this order? Urine myoglobin is present. Osmotic gap less than 10 The client is hypovolemic. Serum albumin is low.
The client is hypovolemic. Mannitol should be given to euvolemic clients. Hypovolemia should be corrected prior to administration of mannitol.
A client who has Open head injury has been prescribed Phenytoin (Dilantin) to reduce the risk of seizures. Concurrent use with which of the following medications should be reported to the provider due to the possibility of a medication interaction? Celexoxib (celebrex) Ciprofloxacin (Cipro) Atrovastatin (Lipitor) Warfarin (Coumadin)
Warfarin (Coumadin) Concurrent use of phenytoin and warfarin can lessen the effectiveness of warfarin. There are no interactions for the others.
Which nursing action would help to optimize the client's cerebral perfusion pressure (CPP)? Have the client assist with moving up in bed by pushing with his feet. When turning the client, treat the body as one continuous unit. Keep the client's head turned to the side. Treat fever with antipyretics as ordered. Position the client in high Fowler's position.
When turning the client, treat the body as one continuous unit. Treat fever with antipyretics as ordered. The client's hips should not flex more than 90 degrees. In high Fowler's position, this is a greater possibility than with the head of the bed lower. Hyperthermia increases cerebral metabolism, which increases blood flow. This blood flow must be controlled within a narrow window. Too much increase in blood flow will increase ICP and decrease perfusion.
When providing care to a client with increased intracranial pressure (IICP) requiring mechanical ventilation, the nurse is aware that intracranial pressure can increase due to: hypoxemia and hypercapnia. oxygenation with a partial pressure of arterial oxygen at about 100 mmHg. partial pressure of arterial carbon dioxide of about 35 mmHg. hyperventilation.
hypoxemia and hypercapnia. Rationale: Hypoxemia and hypercapnia can increase intracranial pressure. It is important to maintain adequate oxygenation with a partial pressure of arterial oxygen at about 100 mmHg and a partial pressure of arterial carbon dioxide of about 35 mmHg. Hyperventilation decreases the PaCO2 and would cause the ICP to decrease.
A young adult client is brought to the emergency room with a suspected narcotic overdose. The client is in respiratory acidosis and has an increased CO2 level with resulting increased intracranial pressure (IICP). The physiologic mechanism contributing to the IICP is: vasoconstriction of cerebral vessels. herniation of the brainstem. vasodilation of cerebral vessels. altered level of consciousness.
vasodilation of cerebral vessels. Rationale: A narcotic overdose depresses the respiratory system and leads to elevated levels of carbon dioxide (CO2) in the blood and respiratory acidosis. High levels of CO2 cause vasodilation of cerebral vessels leading to increased intracranial pressure (IICP). Elevated ICP is not caused by vasoconstriction, and herniation occurs as an end result of delayed or inadequately treated IICP. Altered level of consciousness is a sign of IICP rather than the physiologic mechanism contributing to IICP.
Concussion Treatment
Patients may be observed for 1-2 hrs after initial injury in the ED, then discharged home with instructions for further observation to detect s/s of secondary injury. If LOC extended more then 2 mins the pt. may be admitted to the hospital for observation. A pt. with a mild head injury should be awakened every 2 hours and assessed neurologically. Patients and their caregivers should return to the hospital if there is any of the following: -seizure -confusion -severe/worsening headache -watery discharge from the ear or nose -persistent nausea / vomiting.
The client is diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? A subcutaneous anticoagulant An intravenous osmotic diuretic An oral anticonvulsant An oral proton pump inhibitor
An intravenous osmotic diuretic And osmotic diuretics would be ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.
ICP may be increased by
-Hypercarbia- Cerebral Vasodilation -ET/OT- suctioning -Coughing -Blowing nose frequently -Extreme neck/hip flexion/extension -HOB at 30* or less -Increasing intra abdominal pressure (restrictive clothing/valsalva maneuver)
Indications for surgery include:
-an open skull fracture -a depressed skull fracture of more than 1 cm extra-axial hematoma with a midline shift of greater than 0.5 cm -intra-axial hematoma with a volume greater than 30 ml -a temporal or cerebellar hematoma more than 3 cm
The nurse admits for observation a 70-year-old client with symptoms of increased intracranial pressure (IICP). What diagnostic tests would the nurse not expect to be performed on this elderly client and why? A lumbar puncture to avoid a sudden release of pressure in the skull which might cause cerebral herniation. Computed tomography (CT) scan because of its limited value in determining potential causes of this client's abnormal neurological findings. Cranial nerve testing because his age makes it difficult to assess cranial nerve function. Endoscopy to search for stress gastritis and ulcers which occur more often in this population.
A lumbar puncture to avoid a sudden release of pressure in the skull which might cause cerebral herniation. Rationale: Clients of any age with suspected increased intracranial pressure (IICP) would not be given a lumbar puncture because of the risk of cerebral herniation. Cranial nerve testing, as part of an overall neurological assessment, would be done in all age groups and adapted accordingly. Computed tomography (CT) scans, as well as MRIs, are typical diagnostic tests used to help determine causes of IICP. An endoscopy would not be done as part of the IICP assessment. IICP places individuals at higher risk for developing stress gastritis and ulcers, not the other way around.
the client diagnoses with a mild concussion is being discharged from the ER. Which discharge instruction should the nurse teach the clients significant other? Awaken the client every two hours Monitor for increased intracranial pressure Observe frequently for hypervigilance Offer the client food every three to four hours
Awaken the client every two hours Awakening the client every two hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety-all signs of postconcussion syndrome, That would warrant the significant others taking client back to the emergency department.
The nurse assesses clear fluid coming from the nose and ears of a client admitted to the Emergency Department after a fall. The fluid is found to be cerebral spinal fluid. Based on this information, the nurse plans care for a client with which type of fracture? Basilar Depressed Linear Open
Basilar Otorrhea and rhinorrhea are common with basilar skull fracture.
The nurse is caring for the client with increased intracranial pressure (IICP) from a severe head injury. The nurse monitors the client for symptoms of which complication of IICP? Hydrocephalus Cerebral edema Brain herniation Headache
Brain herniation Rationale: The client with increased intracranial pressure (IICP) is at risk for brain herniation. Cerebral edema and hydrocephalus are causes of IICP. Headache is a symptom rather than a complication of IICP.
The nurse establishes a diagnosis of Ineffective Tissue Perfusion: Cerebral for a client with increased intracranial pressure (IICP). Which interventions would not be included in the client's plan of care? Assess for bladder distention and bowel constipation. Provide a quiet environment, limiting noxious stimuli. Preoxygenate the mechanically-ventilated client with 100% oxygen before suctioning. Cluster nursing care.
Cluster nursing care. Rationale: Nursing care should be planned so that certain activities are not clustered together. For example, turning the client, getting the client on the bedpan, and suctioning should not be done within the same time period since multiple procedures can increase ICP. Nursing care should be scheduled to provide rest periods between procedures. Providing a quiet environment, preoxygenating before suctioning, and assessing for bowel and bladder fullness are appropriate for the client with IICP.
A client sustained a closed head injury in a fall from a tree that happened 2 hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and has a current Glasgow Coma Scale (GCS) score of 11. The nurse should plan care for a client with which level of injury from this contusion? Extreme Severe Mild Moderate
Moderate A GCS of 3-8 indicates severe damage from a contusion. 3-8 Severe head injury 9-12 Moderate head injury 13-15 Mild head injury
An adolescent who has a gunshot went to the critical care unit from the emergency department. Which of the following assessment findings are indicative of increased ICP? Headache Dilated pupils Tachycardia Decorticate posturing Hypotension
Headache Dilated pupils Decorticate posturing Headache, dilated or pinpoint pupils, and decorticate or decerebrate posturing are signs of increased ICP. Bradycardia and hypertension with a lightning post pressure or signs of increased ICP as opposed to tachycardia and hypotension.
The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? Assess neurological status Monitor poles, respiration, and blood pressure Initiate an intravenous access Maintain an adequate airway
Maintain an adequate airway The most important nursing goal in the management of the a head injury is to establish and maintain an adequate airway.
The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain-dead. Which data supports that the client is brain-dead? When the client's head is turned to the right, eyes turn to the right. The electroencephalogram (EEG) has identifiable waveforms. No eye activity is observed when the cold caloric test is performed. The client assumes decorticate posturing when painful stimuli are applied.
No eye activity is observed when the cold caloric test is performed. The cold caloric test, also called the oculovestibular test, Is a test used to determine if the brain is intact or dead. No eye activity indicates brain death. If the client's eyes moved, that would indicate that the brainstem is intact.
The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as "high risk for immobility complications". Which intervention would be included in plan of care? Position the client with the head of the bed elevated at intervals. Perform active range of motion exercises every four hours Turn the client every shift and massage and bony prominences Explain all procedures to the client before performing them
Position the client with the head of the bed elevated at intervals. The head of the clients bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.
A client who sustained a closed head injury has elevation of ICP. Currently the client is putting out nearly a liter of pale urine each hour. The client is diagnosed with diabetes insipidus (DI). The nurse prepares for interventions based on which pathophysiology? The client is producing too much growth hormone (GH). The client is retaining sodium. The client has too much circulating vasopressin (DDAVP). The client is not producing enough antidiuretic hormone (ADH).
The client is not producing enough antidiuretic hormone (ADH). DI is a result of a deficiency in antidiuretic hormone.
The father of an adolescent client with a recent head injury asks the nurse to explain what the family can expect in the way of treatment, especially medications, for their son. The nurse should respond with: "Even though he might be restless, it's probable that he won't be sedated so that we can more accurately monitor his level of consciousness." "Even though he has fluid and swelling inside his head from the injury, he probably won't be given diuretics as these are used more in cardiac clients." "Head injury clients tend to be agitated, so I expect the doctor will keep him sedated to decrease his movement and brain activity." "It's likely he that won't be given anti-fever medications since drugs like acetaminophen are contraindicated in head injury."
"Head injury clients tend to be agitated, so I expect the doctor will keep him sedated to decrease his movement and brain activity." Rationale: The best response that the nurse can give is to tell the father that individuals with head injury and increased intracranial pressure are typically sedated due to restlessness and agitation. Such behavior raises blood pressure, intracranial pressure, and cerebral metabolism, and can cause further damage to the brain. Thus, head injury clients are not kept awake for the purpose of better monitoring of their level of consciousness. Diuretics are considered mainstays in treating clients with Increased ICP (IICP). Antipyretics are also an important adjunct to treatment when clients develop fever since hyperthermia increases cerebral metabolic rate and exacerbates an increase in ICP.
The mother of a 10-year old client asks the nurse, "Why does my son seem so dazed after he has a seizure?" How should the nurse respond? "Seizure activity exhausts energy production in brain cells and may be producing molecules that negatively affect brain function until balance is restored." "Children's brains are less resistant to the effects of seizure activity so they tend to have more confusion afterwards." "The grogginess after a seizure occurs from decreased oxygen getting to the brain during the seizure causing a temporary brain injury." "He's likely just confused about what's happened to him during the seizure and just needs time to recover from the episode."
"Seizure activity exhausts energy production in brain cells and may be producing molecules that negatively affect brain function until balance is restored." Rationale: The spontaneous and disordered discharge of activity occurring during a seizure is thought to exhaust energy metabolites or to produce locally toxic molecules. This affects level of consciousness following a seizure episode until metabolic balance is restored.
Multiple steps should be implemented in the prevention of TBI. These include:
-Wearing a seatbelt and properly securing children in the car -Drive at or below the speed limit -Use helmets when riding motorized vehicles or bikes -Use proper protective gear when playing sports -Practice gun safety -Fall prevention methods -Eliminate tackling from school football for those under 16 in an effort to reduce concussions -More education needs to be included in athletes, coaches, parents, school administrators, health care providers regarding the assessment, prevention and management of concussion
The nurse is providing teaching to a client who is recovering from increased intracranial pressure (IICP). Which instructions should the nurse plan to give the client prior to discharge? (Select all that apply.) There is no need to worry about keeping the head and neck in alignment when turning in bed. Perform isometric or muscle-contracting exercises. Eat a diet high in red meat and chicken. Avoid exposure to people with colds. Avoid straining with bowel movements.
Avoid exposure to people with colds. Avoid straining with bowel movements. Rationale: Straining with bowel movements and performing isometric exercises are to be avoided as these actions increase intracranial pressure. The client should be taught to turn in bed while maintaining the head and neck in alignment. Because coughing, sneezing, and nose blowing can all increase ICP, the client should avoid others with respiratory illness. Diet does not have a great deal of effect on ICP, but red meat is considered an unhealthy choice if eaten frequently.
Mild traumatic brain injury
Glasgow Coma Scale [GCS] between 13 to 15, which is measured 30 minutes after the injury) is typically a benign problem, but it must be carefully considered because there is potential for significant long-term and short-term complications. Mild TBIs often have subtle symptoms such as the patient acting a little strange, blurred vision, tinnitus, confusion, dizziness, fatigue, mood change, sleep disturbance, and inability to concentrate. When a patient presents with a worsening or persistent headache, convulsions, persistent vomiting, decreased level of consciousness, slurred speech, incoordination, agitation, restlessness, abnormal pupil response or weakness/numbness in the extremities, a moderate to severe TBI should be suspected.
A client who has a closed head injury has had ICP readings that ranged between 16-22 mmHg for the past two days. Which of the following actions should the nurse take to decrease the potential for raising the clients ICP? SATA Suction endotracheal tube using a closed system. Hyperventilate the client Elevate the clients head using two pillows Administer a stool softener Keep the client well hydrated
Hyperventilate the client Administer a stool softener Hyperventilation of the client will prevent hypercarbia which can cause vasodilation with a secondary increase in ICP. Administration of a stool softener Will also decrease the need to bear down (valsalva maneuver) during bowel movements, which can increase ICP. Hyper flexion of the clients neck with pillows and overhydration all carry the risk of increasing ICP and should be avoided. Suctioning also increases ICP and should be done only when indicated.
A client who has increased ICP has been prescribed mannitol (Osmitrol) IV. For which of the following side effects should the nurse monitor? Hyperglycemia Hyponatremia Hypervolemia Oliguria
Hyponatremia Mannitol is a powerful osmotic diuretics that carries the risk of fluid and electrolyte imbalances such as hyponatremia. Hyperglycemia is not a side effect of mannitol. Hypovolemia and polyuria our side effects as opposed to hypervolemia and oliguria.
In conducting a Glasgow Coma Scale Assessment on an infant, the nurse understands that the observation made to assess motor response in this age group differs in what way from the observation used in assessing motor response in an adult? Infants are observed for spontaneous movement, while adults are asked to follow a command. The degree of flexion is assessed in infants, but not in adults. Response to pain is not part of the assessment of the infant's motor response, while it is assessed in adults. The eyes open spontaneously in an infant, but only to noise in adults.
Infants are observed for spontaneous movement, while adults are asked to follow a command. Rationale: Motor response in infants using the Glasgow Coma Scale is assessed by observing spontaneous movement, while adults' ability to obey a command to move a body part is used with older children and adults. Observing for spontaneous eye opening is done with both infants and adults, but this assessment is in the category of "Eye opening" rather than "Motor response." Response to pain and degree of flexion are assessments of motor responses conducted on both infants and adults.
The nurse assessing a client with suspected increased intracranial pressure (IICP) should be aware of which physiologic mechanisms related to IICP? (Select all that apply.) In pressure autoregulation, high arterial pressure causes stretch receptors in the brain's small blood vessels to dilate to increase cerebral blood flow Pressure and metabolic autoregulation mechanisms have an unlimited ability to maintain cerebral blood flow by constricting or dilating cerebral arterioles when ICP changes. If the volume of the brain, CSF, or blood in the skull increases, the volume of the others must decrease to maintain normal pressures in the cranium. Vasodilation refers to the relationship between the volume of the intracranial components and intracranial pressure. Interruption of the cerebral blood flow, particularly oxygen and glucose, leads to brain tissue ischemia and disruption of the cerebral metabolism.
Interruption of the cerebral blood flow, particularly oxygen and glucose, leads to brain tissue ischemia and disruption of the cerebral metabolism. If the volume of the brain, CSF, or blood in the skull increases, the volume of the others must decrease to maintain normal pressures in the cranium. Rationale: Interruption of cerebral blood flow leads to ischemia and disrupted cerebral metabolism. Since the cranial cavity can't expand, and the brain, CSF, and blood fill the entire cranium, if one of these substances increases, the volume of the others must decrease to maintain normal pressures. In pressure autoregulation, if the arterial pressure is high, the stretch receptors in the brain's small blood vessels will cause the vessels to constrict, not dilate. This serves to maintain normal pressure. This ability, however, is limited. The relationship between volume and intracranial pressure is called compliance, not vasodilation.
A nurses caring for client client who was recently admitted to the emergency department following a head on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, And a laceration on his four head that is bleeding. Which of the following is the priority nursing action at this time? Keep neck stabilized Insert NG tube Monitor pulse and blood pressure frequently Establish IV access and start fluid replacement
Keep neck stabilized The greatest risk to the client is permanent damage to the spinal cord of a cervical injury does exist. The priority nursing intervention is to keep the neck immobile until damage to the cervical spine can be rolled out. Inserting an NG tube, Monitoring pulse and blood pressure, and establishing IV access for fluid replacement are all important, but not the priority at this time.
A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply. Constricted pupils Apnea Normal temperature Presence of coma Loss of brainstem reflexes
Loss of brainstem reflexes Presence of coma Normal temperature Apnea Loss of brainstem reflexes is a criterion for declaring brain death. Pupils will be fixed and dilated. Apnea is a criterion for declaring brain death.
A client who sustained a head injury has been diagnosed with SIADH. Which nursing action is necessary? Restrict daily intake of protein. Maintain fluid restriction. Administer oral salt tablets as ordered. Administer intranasal vasopressin.
Maintain fluid restriction. The client with SIADH retains too much water. Treatment includes fluid restriction.
The ICU nurse reviewing an intraventricular pressure reading of a client under care for increased intracranial pressure notes a value of 20 mmHg. This requires what action? Continued monitoring of the intracranial pressure Periodic observation for seizure activity Notification of the physician and immediate treatment No special action as this value is within normal limits
Notification of the physician and immediate treatment Rationale: The normal range for intracranial pressure (ICP) in adults is typically 5-15 mmHg. Sustained elevated pressure is 15 mmHg in adults, and a result of 20 mmHG warrants immediate intervention and treatment. Taking no action is not an option. The nurse should continue to carefully observe the client, including observing for seizure activity, but immediate intervention for a 20 mmHg reading is the most critical action by the nurse with a reading at this level.
A nurse is caring for a client who has just been admitted from surgery for the evacuation of a subdural hematoma. Which of is the following assessment? Glasgow coma scale Cranial nerve function Oxygen saturation level Pupillary response
Oxygen saturation level While all of the assessments are important in the care of this client, assessment of the clients oxygen saturation level is the highest priority. Brain tissue can only survive for three minutes without oxygen before permanent damage occurs.
The mother of an adolescent daughter wants to know what they should look for in case the daughter gets hit in the head playing soccer. The nurse notes that four areas of functioning should be assessed if a concussion is suspected, including physical, cognitive, and emotional. The fourth area of functioning to assess is: Sleep Personality Musculoskeletal complaints School performance
Sleep Rationale: Sleep is the fourth area of functioning that the mother and daughter should monitor. Individuals experiencing concussion may be drowsy, sleep more or less than usual, or may have trouble falling asleep.
The nurse is enjoying a day at the lake and witnesses a water skier the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first healthcare provider to respond to the accident. Which intervention would be implemented first? Assess the clients level of consciousness Organize onlookers to remove the client from Lake Perform a head to toe assessment to determine injuries Stabilize the clients cervical spine
Stabilize the clients cervical spine The nurse should always assume that a client with traumatic head injury may have sustained a spinal cord injury. The client could further into the spinal cord and cause paralysis; therefore, the nurse should stabilize the cervical spine import as best as possible prior to removing client client from the water.
The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? Notify the healthcare provider immediately Prepare to administer an antihistamine Test the drainage for presence of glucose Place a 2 x 2 gauze under the nose to collect drainage
Test the drainage for presence of glucose The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid, and the healthcare provider should be notified immediately once this is determined. With head injuries, any clear drainage may indicate a cerebralspinal fluid leak; the nurse should not assume the drainage is secondary to allergies and administer an antihistamine. Placing a 2 x 2 got under the nose would be appropriate but first determine where the fluid is coming from.
The nurse is caring for several clients which client with the nurse assessed first after receiving the shift report? The 22-year-old male diagnosed with a concussion who was complaining someone is waking him up every two hours. The 36-year-old female client admitted with complaints of left-sided weakness who is scheduled for a MRI scan. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident it has a Glasgow coma scale score of six. The 62-year-old client diagnosed with a cerebral vascular accident (CVA) who has expressive aphasia.
The 45 yr old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow coma scale score of six. The Glasgow coma scale is used to determine a clients response to stimuli (I opening response, the best verbal response, and best motor response) secondary to a neurological problem; scores range from 3 (deep coma) to 15 (intact neurological function). A client with the score of 6 should be assessed first by the nurse.
A client was admitted to the ICU after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. The nurse takes action on this assessment for which reason? The client is over-sedated. The client is overtired from the events of the day. The client's ICP may be decreasing. The client's brain injury may be worsening.
The client's brain injury may be worsening. The signs are indicative of deterioration in the client's level of consciousness associated with a worsening of a brain injury.
A client presumed to be brain dead is being assessed for a response to caloric stimulation, the process of irrigating the ear with ice cold water to test the oculovestibular reflex. What finding would be expected if, in fact, the client is brain dead? The eyes would not move toward the irrigated side. The eyes would move to the side opposite the irrigated side. Dilation of both pupils would occur with the irrigation. The eyes would move toward the irrigated side and then return to midline.
The eyes would not move toward the irrigated side. Rationale: A normal response to the caloric stimulation test is for the client's eyes to move first toward the irrigated side, followed by a return to midline. Thus, in an individual with brain death on whom caloric stimulation is conducted, the eyes will not move first toward the irrigated side and then return to midline. Pupillary dilation is not what is examined with this particular procedure.
A client with cerebral edema is prescribed intravenous mannitol. In planning care for this client, the nurse recognizes that the purpose for administering this medication is to: help manage seizure activity associated with increased intracranial pressure (IICP). decrease the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys. increase osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys. promote diuresis by acting on the renal tubules.
increase osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys. Rationale: Mannitol is an osmotic diuretic that increases the osmolarity of the blood, thereby drawing water out of edematous brain tissue and into the vascular system for elimination via the kidneys. Loop diuretics act on the renal tubule to inhibit reabsorption of sodium and chloride leading to a decreased rate of CSF production. Anticonvulsants are administered to manage seizure activity associated with increased intracranial pressure (IICP).
