Head Injury
A patient sustained a head injury two days ago. The patient asks the nurse if a hot bath could be provided. How should the nurse respond? "You should take a lukewarm bath." "You can take a hot bath as long as the wound stays dry." "You may take a hot bath with assistance." "Do you have non-slip mats in your bathtub?"
"You should take a lukewarm bath." Hot baths should be avoided for patients recovering from head injuries because the hot water causes changes in blood pressure which may affect the blood flow to the brain, causing lightheadedness or dizziness. "You can take a hot bath as long as the wound stays dry." While the wound should be kept clean and dry, this is not appropriate advice for a patient recovering from a head injury. "You may take a hot bath with assistance." While assistance with bathing may be important for patient safety precautions, this is not appropriate advice for a patient recovering from a head injury. "Do you have non-slip mats in your bathtub?" While non-slip bath mats are important for patient safety reasons, addressing this fact is not the most appropriate response by the nurse.
Match the types of skull fractures with their description. 1) Inward indentation of the skull 2) Linear or depressed fracture without fragmentation 3) Multiple fractures with bone fragmentation 4) Depressed fracture with scalp laceration A. Linear B. Depressed C. Compound D. Simple E. Comminuted
1) B 2) D 3) E 4) C
Match the type of subdural hematoma with its progression of symptoms. 1) Immediate deterioration 2) Progressive alteration in LOC with a nonspecific progression 3) Alteration in mental status progresses as hematoma develops A. Mild B. Subacute C. Chronic D. Acute
1) D 2) C 3) B
A nurse is caring for a patient who recently suffered a traumatic brain injury. The patient complains of severe headache, nausea and vomiting, and is irritable. The nurse notes increased blood pressure and a fixed right pupil. Which action would the nurse take first? Administer IV phenergan Elevate the head of the bed Administer oral pain medication Place the patient in a supine position
Administer IV phenergan The patient's symptoms indicate worsening ICP. Phenergan is used to treat nausea and vomiting, but should be avoided in patients with increased ICP because it can mask the signs of worsening neurological status. Elevate the head of the bed The patient's symptoms indicate worsening ICP. Elevating the head of the bed helps to facilitate drainage of CSF in a patient with increased ICP. Administer oral pain medication The patient's symptoms indicate worsening ICP. The patient may need pain medication, but because the patient is actively vomiting, the nurse would not administer oral medication. Place the patient in a supine position The patient's symptoms indicate worsening ICP. Patients with increased ICP should not be placed in a supine position because it does not facilitate drainage of CSF.
A patient is recovering well following a craniectomy. Once the patient has fully recovered, the collaborative care team should expect the patient to undergo which procedure? CT scan Burr hole Cranioplasty Ventricular shunt
CT scan A CT scan is a diagnostic procedure and would not be necessary for a patient recovering from craniotomy. Burr hole Burr holes allow for relief of increased ICP in patient suffering from an acute problem. A patient who has undergone craniotomy would already have their increased ICP relieved by opening the cranium and would not require further relief with a burr hole procedure. Cranioplasty A cranioplasty will be necessary in order to repair the skull and replace the removed bone flap. Ventricular shunt Ventricular shunt is used to redirect CSF and would not be necessary following a craniotomy, which allows for the surgeon to drain blood and relieve increased ICP.
An older patient was found unconscious at home and was brought to the hospital. Upon arrival at the emergency department (ED), the patient regained consciousness and spoke with the nurses. During the initial assessment the patient complained of a headache immediately before losing consciousness again. These are all classic manifestations of which head trauma complication? Epidural hematoma Subdural hematoma Subacute hematoma Subarachnoid hematoma
Epidural hematoma Classic signs of an epidural hematoma include an initial period of unconsciousness at the scene, with a brief lucid interval followed by a decrease in level of consciousness (LOC). Other manifestations may be a headache, nausea and vomiting, or focal findings. Subdural hematoma Signs and symptoms of subdural hematoma are similar to those associated with brain tissue compression in increased intracranial pressure (ICP) and include decreasing level of consciousness (LOC) and headache. Subacute hematoma Subacute hematoma is not a form of hematoma but a description of symptom progression, occurring 48 hours to 2 weeks after severe trauma. Subarachnoid hematoma Subarachnoid hematoma is not associated with alternating periods of lucidity and unconsciousness.
Which incidents are the most common causes of head injury? Select all that apply. Falls Assaults Car accidents Gunshot wounds Sports-related trauma
Falls Falls are one of the leading causes of head injury. Assaults Assaults can cause head injury, but is not one of the primary causes. Car accidents Motor vehicle collisions are one of the leading causes of head injury. Gunshot wounds Gunshot wounds can cause head injuries but are not the primary reason for head injury. Sports-related trauma Even though sports-related trauma can cause head injury, it is not one of the most common causes.
A nurse is assessing a patient following a head trauma. Which assessment findings are consistent with a diagnosis of Cushing's triad? Select all that apply. Heart rate of 52 beats per minute Pulses that seem thready in nature Irregular breathing pattern Systolic blood pressure reading of 178 mm Hg Initial blood pressure reading of 160/45 mm Hg with later reading of 189/32 mm Hg
Heart rate of 52 beats per minute Cushing's triad symptoms include bradycardia with full and bounding pulse. Pulses that seem thready in nature Cushing's triad is a sign of impending herniation, and includes bounding, not thready pulses. Irregular breathing pattern Cushing's triad symptoms include irregular respirations. Systolic blood pressure reading of 178 mm Hg Systolic hypertension is a symptom of Cushing's triad. Initial blood pressure reading of 160/45 mm Hg with later reading of 189/32 mm Hg Widening pulse pressure is a symptom of Cushing's triad.
The nurse is caring for a patient who presents with an actively bleeding head wound. The patient is obtunded, with one fixed pupil. The pulse is thready and respiratory effort is increased. Which provider orders would the nurse anticipate? Select all that apply. Insert urinary catheter Prepare for intubation Insert nasogastric tube Administer intravenous (IV) dextrose 5% Administer intravenous (IV) 0.9% saline
Insert urinary catheter Patients with head injuries require a urinary catheter to monitor urinary output, but this is not a priority intervention given the patient's symptoms. Prepare for intubation Patients with head injuries who are obtunded with pinpoint pupils and increased respiratory effort should be intubated. Insert nasogastric tube Nasogastric tubes should not be inserted in patients with head injuries because of the risk for basilar skull fractures and brain trauma. Administer intravenous (IV) dextrose 5% Patients with head injuries should not receive dextrose as an IV fluid, as it may increase reduce serum sodium and increase brain water and ICP. Administer intravenous (IV) 0.9% saline Patients with head injuries should be treated with 0.9% Normal Saline to help fluid shift from the cerebral space back into the cells, decreasing ICP.
The medical team reports a score of seven on the Glasgow Coma Scale (GCS) during initial assessment of a patient with a head trauma. What is the next step in the patient's treatment? Intubation Burr hole procedure Computerized tomography (CT) scan Positron emission tomography (PET) scan
Intubation Patients with a GCS score below eight, which indicates severe head injury, require immediate intubation to allow for mechanical ventilation and to protect the airway. (Less than 8, intubate) Burr hole procedure Burr holes may be necessary, but the procedure will not be performed until a diagnosis is confirmed. Computerized tomography (CT) scan A CT scan will help to diagnose the patient's head injury, but is not the priority for a patient with GCS score of seven or below. Positron emission tomography (PET) scan A PET scan may be performed, but is not the priority for a patient with a GCS score of seven or below.
In the acute phase after head injury, how can the nurse determine the progression of the patient's injury? Monitor patient vital signs Administer fluids and note results Ask questions to determine cognition Prepare patient for surgical evacuation of blood
Monitor patient vital signs While monitoring patient vital signs is important for ongoing nursing management, it does not help the nurse determine how the patient's head injury has progressed or monitor for worsening neurological function. Administer fluids and note results Fluids should be administered cautiously to prevent fluid overload and increasing ICP, but this would not help the nurse determine how the patient's head injury is progressing. Ask questions to determine cognition Frequent neurological checks are completed to assess the progression of the patient's injury, to monitor for worsening neurological function and recognize decompensation early. Prepare patient for surgical evacuation of blood Surgical evacuation of blood would be performed after the neurological progression of the patient's head injury is already known and deemed to be serious, but would not help to determine the progression of injury.
A patient is admitted to the hospital following a motor vehicle accident. The patient has an oval shaped bruise behind the right ear in the mastoid region, a very runny nose, and is unable to move the muscles in the right side of his face. Which skull fracture do these clinical manifestations correspond to? Orbital fracture Frontal fracture Basilar skull fracture Posterior fossa fracture
Orbital fracture Orbital fracture is characterized by periorbital ecchymosis and optic nerve injury. Frontal fracture Frontal fractures are characterized by cerebrospinal fluid (CSF) rhinorrhea, pneumocranium and exposure of brain tissue. Basilar skull fracture Basilar skull fracture is characterized by Battle's sign, rhinorrhea and facial paralysis, in addition to cerebrospinal fluid (CSF) or brain otorrhea, bulging of tympanic membrane caused by blood or CSF, tinnitus or hearing difficulty, conjugate deviation of gaze and/or vertigo. Posterior fossa fracture Posterior fossa fracture is characterized by occipital bruising, vision deficits, and ataxia.
A nurse is educating the patient and family about signs of head injury complications that should be reported to the health care provider. Which signs and symptoms should be included in the teaching? Select all that apply. Slurred speech Severe headache Difficulty waking up New onset irritability Development of hearing problems
Slurred speech Slurred speech, or other motor problems such as clumsiness, difficulty walking, and weakness in arms or legs, are signs of complications from head injuries, and should be reported to the health care provider. Severe headache Severe headache, that worsens over time or is associated with a stiff neck is a sign of complications from head injuries, and should be reported to the health care provider. Difficulty waking up Increased drowsiness is a possible complication from head injuries, and should be reported to the health care provider. New onset irritability Behavioral changes that include new onset irritability or anger, are signs of possible complication after head injuries, and should be reported to the health care provider. Development of hearing problems Development of hearing problems is not a sign of complications stemming from head injuries.
A patient with rapidly increasing ICP had an emergency craniotomy to relieve the pressure. Now that the patient is stable, which action should the care team perform? Cranioplasty Initiate IV access Ventricular shunt Transport to CT scan
Cranioplasty A cranioplasty may be required, but will not be completed until the patient's condition has been diagnosed. Initiate IV access IV insertion would be completed prior to placing burr holes, not after. Ventricular shunt Ventricular shunts redirect CSF fluid, but would not be placed until diagnosis is confirmed. Transport to CT scan Once the patient is stable, the collaborative care team should complete a CT scan to quickly diagnose the reason for the increased ICP.
During assessment of a patient with head trauma, the nurse notes slurred speech and a right sided facial droop. Which action should the nurse take? Select all that apply. Determine the patient's pain level Auscultate the patient's bowel sounds Assess the patient's airway patency Visualize the patient's pupillary response Evaluate the patient's level of consciousness
Determine the patient's pain level Pain level is an important assessment, but is not priority for a patient with slurred speech and facial droop. Auscultate the patient's bowel sounds Bowel sounds are included in the head to toe exam of all patients, but are not the priority for a patient with slurred speech and a facial droop. Assess the patient's airway patency Patients with facial droop and signs of neurological compromise should have their airway assessed to ensure it remains patent. Visualize the patient's pupillary response Pupillary response should be assessed to help diagnose the location and severity of head trauma. Evaluate the patient's level of consciousness Level of consciousness should be assessed for changes that may indicate cerebral hemorrhage.
Which surgical procedure should be performed in a patient who has suffered a depressed skull fracture? Craniotomy Cranioplasty Craniectomy Ventricular shunt
Craniotomy Craniotomy is a procedure performed to remove a lesion, repair a damaged area, drain blood, or relieve increased ICP, not to repair a skull fracture. Cranioplasty Cranioplasty is performed to repair a cranial defect, such as a depressed skull fracture, resulting from trauma, malformation, or previous surgical procedure. Craniectomy Craniectomy is used to excise into the cranium to cut away bone flap, not to repair a skull fracture. Ventricular shunt Ventricular shunts provide an alternate pathway for CSF collecting in the brain, not to repair skull fractures.
A patient who has suffered an epidural hematoma is experiencing increased ICP. What surgical procedure should the collaborative care team perform? Craniotomy Cranioplasty Stereotactic biopsy Ventricular shunt
Craniotomy Craniotomy, which involves removing a part of the skull, should be used decrease ICP for a patient with an epidural hematoma. Cranioplasty Cranioplasty is used to repair deformities in the skull. It will not correct ICP related to an epidural hematoma. Stereotactic biopsy Stereotactic procedures are used to localize the specific area of injury in order to perform a biopsy, radiosurgery or dissection. Stereotactic procedures are not used to decrease ICP. Ventricular shunt Ventricular shunts are used to provide an alternate pathway for CSF collecting in the brain.
Why is a CT scan the best diagnostic test for evaluating acute head trauma? Measures cerebral blood flow velocity Useful in detecting small lesions Most sensitive imaging technique Allows for rapid diagnosis and intervention
Measures cerebral blood flow velocity Transcranial Doppler studies, not CT scans, are used to measure cerebral blood flow (CBF) velocity. Useful in detecting small lesions Magnetic Resonance Imaging (MRI) scans, not CT scans, are ideal at detecting small lesions. Most sensitive imaging technique Magnetic Resonance Imaging (MRI) is considered a more sensitive imaging technique than CT. Allows for rapid diagnosis and intervention CT scan is best for evaluating acute head trauma because the procedure is quick and can be performed in an acute care setting.
