Head Trauma

The nurse is caring for a patient in the neurologic ICU who sustained head trauma in a physical altercation. What would the nurse know is an optimal range of ICP for this patient?

0 to 10 mm Hg

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1- Decreased intravascular volume 2- Increased intracranial pressure (ICP) 3- Ischemic cerebrovascular accident (CVA) 4- Brain tissue necrosis

2

An osmotic diuretic such as mannitol is given to the client with increased intracranial pressure (ICP) to 1- control fever. 2- control shivering. 3- dehydrate the brain and reduce cerebral edema. 4- reduce cellular metabolic demand.

3- dehydrate the brain and reduce cerebral edema.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered

4

Which condition occurs when blood collects between the dura mater and arachnoid membrane? 1- Intracerebral hemorrhage 2- Epidural hematoma 3- Extradural hematoma 4- Subdural hematoma

4

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)? 1- Encouraging oral fluid intake 2- Suctioning the client once each shift 3- Elevating the head of the bed 90 degrees 4- Administering a stool softener as ordered

4- Administering a stool softener as ordered

What does the nurse recognize as the earliest sign of serious impairment of brain circulation related to increasing ICP? 1- A bounding pulse 2- Bradycardia 3- Hypertension 4- Lethargy and stupor

4- Lethargy and stupor

A client has been diagnosed with a concussion and is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the client to contact the physician or return to the ED if the client 1- reports a headache. 2- reports generalized weakness. 3- sleeps for short periods of time. 4- vomits.

4- vomits.

A patient is admitted to the hospital with an ICP reading of 20 mm Hg and a mean arterial pressure of 90 mm Hg. What would the nurse calculate the CPP to be?

70 mm Hg

A client is receiving intravenous (IV) mannitol to prevent increased intracranial pressure. The order is for mannitol 1.5 grams per kg of body weight IV now. The client weighs 143 lbs. How many grams will the nurse administer to the client? Enter the correct number ONLY.

97.5

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

A client is transferred to the intensive care unit after evacuation of a subdural hematoma. Which nursing intervention reduces the client's risk of increased intracranial pressure (ICP)?

Administering a stool softener as ordered

Which of the following positions are employed to help reduce intracranial pressure (ICP)?

Avoiding flexion of the neck with use of a cervical collar

A nurse is caring for a patient who has suffered an unstable thoracolumbar fracture. Which of the following is the priority during nursing care? A) Preventing infection B) Maintaining spinal alignment C) Maximizing function D) Preventing increased intracranial pressure

B

A female client is being treated for increased intracranial pressure (ICP). Why should the nurse ensure that the client does not develop hypothermia? Choose the correct option.

Because shivering in hypothermia can increase ICP

Which of the following is the earliest sign of increasing ICP?

Change in level of consciousness

Which of the following is the earliest sign of increasing ICP?

Change in level of consciousness (LOC)

client was running along an ocean pier, tripped on an elevated area of the decking, and struck his head on the pier railing. According to his friends, "He was unconscious briefly and then became alert and behaved as though nothing had happened." Shortly afterward, he began complaining of a headache and asked to be taken to the emergency department. If the client's intracranial pressure (ICP) is increasing, the nurse should expect to observe which sign first?

Declining level of consciousness (LOC)

The nurse is caring for a patient postoperatively after intracranial surgery for the treatment of a subdural hematoma. The nurse observes an increase in the patient's blood pressure from the baseline and a decrease in the heart rate from 86 to 54. The patient has crackles in the bases of the lungs. What does the nurse suspect is occurring?

Increased ICP

When obtaining the vital signs of a client with multiple traumatic injuries, a nurse detects bradycardia, bradypnea, and systolic hypertension. The nurse must notify the physician immediately because these findings may reflect which complication?

Increased intracranial pressure (ICP)

A client with a traumatic brain injury is showing early signs of increasing intracranial pressure (ICP). While planning care for this client, what would be the priority expected outcome?

Maintains a patent airway

A client is exhibiting signs of increasing intracranial pressure (ICP). Which intravenous solution (IV) would the nurse anticipate hanging?

Mannitol(Osmitrol)

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol+

A female patient is receiving hypothermic treatment for uncontrolled fevers related to increased intracranial pressure (ICP). Which of the following assessment finding requires immediate intervention?

Shivering

An osmotic diuretic, such as mannitol, is given to the patient with increased intracranial pressure (IICP) for which of the following reasons?

To dehydrate the brain and reduce cerebral edema

A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include:

diminished responsiveness.

A client was hit in the head with a ball and knocked unconscious. Upon arrival at the emergency department and subsequent diagnostic tests, it was determined that the client suffered a subdural hematoma. The client is becoming increasingly symptomatic. How would the nurse expect this subdural hematoma to be classified? 1- acute 2- chronic 3- subacute 4- intracerebral

1

A neurological nurse is conducting a scheduled assessment of a patient who is receiving care on the unit. The nurse is aware of the need to conduct a vigilant assessment of the patient's level of consciousness (LOC). How should the nurse best gauge a patient's LOC? 1- By assessing according to the Glasgow Coma Scale (GCS) 2- By eliciting the patient's response to a question requiring judgment 3- By engaging the patient in a conversation, if possible 4- By observing the patient's interactions with caregivers

1

When performing a postoperative assessment on a client who has undergone surgery to manage increased intracranial pressure (ICP), a nurse notes an ICP reading of 0 mm Hg. Which action should the nurse perform first?1- Check the equipment. 2- Contact the physician to review the care plan. 3- Continue the assessment because no actions are indicated at this time. 4- Document the reading because it reflects that the treatment has been effective.

1- Check the equipment

A client with a traumatic brain injury has already displayed early signs of increasing intracranial pressure (ICP). Which of the following would be considered late signs of increasing ICP? 1- Decerebrate posturing and loss of corneal reflex 2- Loss of gag reflex and mental confusion 3- Complaints of headache and lack of pupillary response 4- Mental confusion and pupillary changes

1- Decerebrate posturing and loss of corneal reflex

While snowboarding, a fell and sustained a blow to the head, resulting in a loss of consciousness. The client regained consciousness within an hour after arrival at the ED, was admitted for 24-hour observation, and was discharged without neurologic impairment. What would the nurse expect this client's diagnosis to be? 1- concussion 2- laceration 3- contusion 4- skull fracture

1- concussion

The initial sign of increasing intracranial pressure (ICP) includes 1- decreased level of consciousness. 2- herniation. 3- vomiting. 4- headache.

1- decreased level of consciousness.

A client is being treated for increased intracranial pressure (ICP). The nurse should ensure that the client does not develop hypothermia because: 1- shivering in hypothermia can increase ICP. 2- hypothermia is indicative of severe meningitis. 3- hypothermia is indicative of malaria. 4- hypothermia can cause death to the client.

1- shivering in hypothermia can increase ICP.

A client suffered a closed head injury in a motor vehicle collision, and an ICP monitor was inserted. In the occurrence of increased ICP, what physiologic function contributes to the increase in intracranial pressure? 1- vasodilation 2- vasoconstriction 3- hypertension 4- increased PaO

1- vasodilation

The nursing instructor is teaching about hematomas to a pre-nursing pathophysiology class. What would the nursing instructor describe as an arterial bleed with rapid neurologic deterioration? 1- Extradural hematoma 2- Epidural hematoma 3- Subdural hematoma 4- Intracranial hematoma

2

A fall during a rock climbing expedition this morning has caused a 28-year-old woman to develop an epidural hematoma. Immediate treatment is being organized by the emergency department team because this woman faces a risk of serious neurological damage as a result of: 1- Decreased intravascular volume 2- Increased intracranial pressure (ICP) 3- Ischemic cerebrovascular accident (CVA) 4- Brain tissue necrosis

2- Increased intracranial pressure (ICP)

The nurse in the neurologic ICU is caring for a client who sustained a severe brain injury. Which nursing measures will the nurse implement to help control intracranial pressure (ICP)? 1- Position the client in the supine position 2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg 3- Restrain the client, as indicated 4- Administer enemas, as needed

2- Maintain cerebral perfusion pressure from 50 to 70 mm Hg

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: 1- Increasing intracranial pressure (ICP) 2- An epidural hematoma 3- Leakage of cerebrospinal fluid (CSF) 4- Meningitis

3

A patient sustained a head trauma in a diving accident and has a cerebral hemorrhage located within the brain. What type of hematoma is this classified as? 1- An epidural hematoma 2- An extradural hematoma 3- An intracerebral hematoma 4- A subdural hematoma

3

The nurse is caring for a patient in the emergency department with a diagnosed epidural hematoma. What procedure will the nurse prepare the patient for? 1- Hypophysectomy 2- Application of Halo traction 3- Burr holes 4- Insertion of Crutchfield tongs

3

A 22-year-old man is being closely monitored in the neurological ICU after suffering a basal skull fracture during an assault. The nurse's hourly assessment reveals the presence of a new blood stain on the patient's pillow that is surrounded by a stain that is pale yellow in color. The nurse should follow up this finding promptly because it is suggestive of: 1- Increasing intracranial pressure (ICP) 2- An epidural hematoma 3- Leakage of cerebrospinal fluid (CSF) 4- Meningitis

3- Leakage of cerebrospinal fluid (CSF)

A client with a concussion is discharged after the assessment. Which instruction should the nurse give the client's family? 1- Have the client avoid physical exertion 2- Emphasize complete bed rest 3- Look for signs of increased intracranial pressure 4- Look for a halo sign

3- Look for signs of increased intracranial pressure

In your assessment of a 39-year-old victim of a motor vehicle collision, he directly and accurately answers your questions. Beginning at his head, you note a contusion to his forehead; the client reports a headache. As you assess his pupils, what reaction would confirm your suspicion of increasing intracranial pressure?

Unequal response