HESI Med-Surg TBI Case Study

Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all that apply.) A. Assess for tinnitus or hearing difficulty. B. Observe the area behind Jeff's ears. C. Observe the area around Jeff's eyes. D. Test Jeff's ability to follow complex directions. E. Check Jeff's ear cavity for leaking fluid.

*A. Assess for tinnitus or hearing difficulty.* These are manifestations of a basilar skull fracture.These are manifestations of a basilar skull fracture. *B. Observe the area behind Jeff's ears.* Battle's sign refers to ecchymosis behind the ears, and it is a common manifestation of aBattle's sign refers to ecchymosis behind the ears, and it is a common manifestation of a traumatic brain injury. traumatic brain injury. *C. Observe the area around Jeff's eyes.* Periorbital ecchymosis, also called "raccoon eyes," is a common manifestation of a basilarPeriorbital ecchymosis, also called "raccoon eyes," is a common manifestation of a basilar skull fracture, along with a positive Battle's sign. *E. Check Jeff's ear cavity for leaking fluid.* Otorrhea is cerebrospinal fluid leakage from the ear and generally confirms that the fracture. Otorrhea is cerebrospinal fluid leakage from the ear and generally confirms that the fracture has traversed the dura.

Which components are measured by the GCS? A. Verbal response, motor response, and eye opening B. Seizure activity, muscle strength, and range of motion. C. Gag reflex, Patellar reflex, and Babinski reflex. D. Pupillary response, visual field, and visual acuity.

*A. Verbal response, motor response, and eye opening* The GCS measures responses that are spontaneous and completely oriented to responses only from noxious stimuli to no response at all. The client is observed for abnormal decorticate (flexor) and decerebrate (extensor) posturing as part of the motor response to a stimulus

This score indicates which finding to the nurse? A. Resolving neurologic condition B. Declining neurologic condition C. Loss of consciousness D. Poor chance of recovery

*B. Declining neurologic condition.* The GCS numerical rating ranges from 3 to 15, with 15 being the best rating, and 3 indicating a poor prognosis and high mortality rate. Any decrease of two points or more is considered significant, requiring notification of the physician.

What is the nurse's best response to Jeff's refusal to see his friends? A. "Your friends may be able to help you cope better to the situation." B. "It might be a good idea to wait a while before you visit with your friends." C. "You sound concerned about how your friends will react when they see you." D. "How do you think your friends will feel if you refuse to see them?"

*C. "You sound concerned about how your friends will react when they see you."* This is a therapeutic response, which clarifies the client's concerns and allows for further communication

Which sign is the most important early indicator of increasing ICP? A. Changes in extraocular eye movement. B. Changes in vital signs. C. Change in level of consciousness. D. Vomiting.

*C. Change in level of consciousness* A change in LOC is the single most significant indicator of deterioration in neurologic function

Jeff is medicated and reports that his headache is relieved. The nurse continues to monitor Jeff's vital signs, and his neurologic status is assessed using the Glasgow Coma Scale (GCS). The nurse's assessment findings are as follows: Jeff's eyes open in response to verbal stimuli Jeff oriented to person only Jeff pulls his arm away and he moves his arm in response to a needle prick. What is the Glasgow Coma Scale rating obtained in this assessment? (Enter numerical value only)

*11*

The nurse prepares to administer Furosemide (Lasix) 20 mg IVP. The drug availability is Lasix 10 mg/mL. How many mL should the nurse administer IVP? (Enter numerical value only. If rounding is necessary, round to the whole number.)

*2*

Which documentation indicates that the expected outcome of the mechanical ventilation was achieved? A. Client exhibits no signs or symptoms of increased ICP. B. Client's ABG results are within normal limits (WNL). C. Client's electrolytes are within normal limits (WNL). D. Client remains afebrile

*A. Client exhibits no signs or symptoms of increased ICP.* The goal of hyperventilation is to maintain cerebral oxygenation and prevent an increase in ICP by maintaining the PCO2 at a low normal level

Priority nursing diagnoses when planning care for a client with increased ICP include: Decreased intracranial adaptive capacity. Ineffective tissue perfusion (cerebral). Risk for injury. The HCP prescribes the following for Jeff: 0.9 Normal Saline at 30 mL/hour. 20% mannitol IVPB every 12 hours. Furosemide 20 mg IVP following mannitol (Osmitrol). Dexamethasone 4 mg IVP every 6 hours. Phenytoin 100 mg IVP every 8 hours. Which medications can be mixed with the other medications? (Select all that apply.) A. Mannitol. B. Furosemide. C. Dexamethasone. D. Phenytoin.

*A. Mannitol.* This is an osmotic diuretic that is compatible in a y-site with furosemide and dexamethasone. *B. Furosemide.* Furosemide is a loop diuretic that is compatible in a y-site with mannitol and dexamethasone. *C. Dexamethasone.* This is a glucocorticoid and is compatible in a y-site with mannitol and furosemide

The next morning, the charge nurse is making nursing care assignments. Several tasks must be performed immediately, and only a nurse and a UAP are available. Which interventions must be performed by the nurse? (Select all that apply.) A. Obtain an oxygen saturation level on a postoperative client. B. Assess an older adult client with dyspnea. C. Ambulate a client in the hallway. D. Assist a client who has vomited to change the hospital gown. E. Provide discharge instructions to a client ready to go home

*B. Assess an older adult client with dyspnea.* The nurse should be assigned this responsibility. Of the four tasks, this requires the highest level of expertise to assess the client's current condition and response to the treatment. (Always remember ABCs.) *E. Provide discharge instructions to a client ready to go home.* Discharge teaching must be performed by the nurse. This intervention may not be delegated to the UAP.

Jeff shares with the nurse that he and his friends had a "couple of beers" the night of the accident. He states, "I guess I had to learn this lesson the hard way." Later that evening, the nurse discusses what Jeff has said with another nurse. This conversation takes place in the hospital cafeteria, where it is overheard. Since Jeff's family is prominent in the community, the information about alcohol use is leaked to the media, who call the nursing supervisor to confirm the report. Before responding to the media, which information is of primary concern to the supervisor? A. Does the reporter work for a reputable news agency? B. Has the client signed a release of information? C. How did the leak occur? D. Have the nurses been reprimanded?

*B. Has the client signed a release of information?* All clients have the right to confidentiality. It is the responsibility of the nurse to safeguard client information

Which nursing intervention should be initiated to prevent increased ICP? A. Keep neck flexed. B. Keep the head of the bed elevated at 30 degrees. C. Perform passive range of motion on extremities. D. Suction airway as needed for at least 15 seconds each time.

*B. Keep the head of the bed elevated at 30 degrees.* Activities such as performing a Valsalva maneuver, coughing, and vomiting should be prevented, since they may cause an increase in ICP. In addition, the client should be positioned with the head of the bed elevated about 30 degrees, and neck flexion and extension should be avoided.

The onset of bacterial meningitis is considered a medical emergency. Jeff is immediately started on IV antibiotics and placed in isolation for the first 24 hours after the initiation of his antibiotic therapy. Priority nursing diagnoses, all related to increasing intracranial pressure secondary to the inflammation and meningeal irritation include pain, ineffective tissue perfusion (cerebral), risk for injury, and risk for ineffective breathing pattern. Which additional nursing diagnosis is important to include when planning Jeff's care during this period? A. Fluid volume excess. B. Risk for impaired physical mobility. C. Risk for constipation. D. Ineffective coping.

*B. Risk for impaired physical mobility.* Clients with meningitis may experience a prolonged recovery time and may experience hemiparesis, dysphasia, and hemianopsia

The nurse has completed discharge teaching for Jeff and his parents. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate? A. "I'll be as doing everything I used to do very soon." B. "I will have to take precautions to prevent the pressure in my brain from increasing again." C. "I may never be back to my former self." D. "I will never be able to live on my own."

*C. "I may never be back to my former self."* For the most part, people who experience a mild to severe traumatic brain injury are never the same again. Long-term effects may include altered cognitive, motor, sensory, or emotional functioning. Progressive recovery generally occurs for the first six months before a plateau is reached, and some problems, such as post-injury seizures, may not occur until several years after the injury.

Which nursing intervention should the nurse include when administering the mannitol? A. Monitor hematocrit and hemoglobin levels B. Titrate administration rate to produce a urine output of 20 mL/hr C. Administer by IV infusion undiluted D. Administer via a central line

*C. Administer by IV infusion undiluted.* Mannitol (Osmitrol) is a hypertonic solution used to reduce intracranial pressure. Mannitol (Osmitrol) is often given with a diuretic, such as furosemide (Lasix). It should be administered undiluted, but through a filter to prevent the administration of any particulates

Jeff's condition gradually improves. He is no longer in isolation, and several of his friends are planning to visit him. Although Jeff's condition is improving, he reports occasional periods when he feels fuzzy-headed, and he has trouble understanding all the words in a conversation. He tells the nurse he does not want to see any of his friends because he thinks of himself as a freak who can't even think straight anymore. Which statement about adolescents should guide the nurse's response? A. Adolescents need to create or nurture things that will outlast them. B. Adolescents need to form loving relationships with other people. C. Adolescents need to develop a sense of self and personal identity. D. Adolescents need to begin to assert control and power over their environment.

*C. Adolescents need to develop a sense of self and personal identity.* The adolescent becomes less reliant on the family and much more reliant on the peer group for a sense of identity.

Jeff is discharged, accompanied by his parents. He continues to exhibit some impaired memory, occasional emotional outbursts, and difficulty following long conversations, which all seem to be related to traumatic brain injury. Jeff's nurse is invited to discuss risk factors related to traumatic brain injury at Jeff's high school. Which is the most significant behavior change in adolescent behavior needed to reduce traumatic brain injuries? A. Never use an electronic device while driving. B. Minimize distractions while driving. C. Never get in a vehicle with someone who has been drinking alcohol. D. Drive only during daylight hours

*C. Never get in a vehicle with someone who has been drinking alcohol.* Sixty percent of all head injuries are alcohol-related. The vast majority of these occur between the ages of 10 to 39, with the peak incidence between the ages of 15 to 24

What method can the nurse use to determine if the drainage is CSF? A. Test the fluid for glucose. B. Observe for blood in the drainage. C. Observe for a "halo" around a spot of drainage. D. Note the amount of the drainage.

*C. Observe for a "halo" around a spot of drainage.* When a drop of the drainage is placed on a white dressing, the CSF will separate from the blood and form a "halo" around the blood. Other measures the nurse can use include observing the appearance of the drainage and using a dextrostick to assess for the presence observing the appearance of the drainage and using a dextrostick to assess for the presence of glucose in the drainage. CSF is clear. However, the CSF may be mixed with blood, so appearance alone may not be a true indicator of CSF. CSF contains glucose, unlike normal nasal drainage. However, a false positive for glucose may be obtained if the CSF is mixed with blood, since blood also contains glucose!

Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP? A. PO2 of 90 and PCO2 of 50. B. PO2 of 97 and PCO2 of 45. C. PO2 of 97 and PCO2 of 35. D. PO2 of 88 and PCO2 of 18.

*C. PO2 of 97 and PCO2 of 35* The PO2 should be maintained close to, or even slightly greater than 100 to promote cerebral oxygenation. The PCO2 indicates a low normal level, which will prevent the vasodilation that occurs with hypercapnia. Studies have shown that aggressive hyperventilation may contribute to focal cerebral ischemia.

On the evening that Jeff is transferred to the Surgical Nursing Unit, he asks to see the nurse. He tells the nurse he needs to talk about something, but he will only do so if it is kept confidential. What is the best response by the nurse? A. "Let me close the door so that we can talk privately." B. "Anything you tell me is completely confidential." C. "As a nurse, I must document everything that happens between us and other people have access to the information." D. "While I can keep many things confidential, there are instances where I may have to share some information."

*D. "While I can keep many things confidential, there are instances where I may have to share some information."* Since Jeff's parents are legally responsible for his care, knowledge which is harmful may need to be shared by the nurse

Jeff requests something for his headache. Which medication is best for the nurse to administer to Jeff for his complaint of headache? A. Morphine sulfate B. Oxycodone/aspirin (Percodan) C. Hydrocodone/acetaminophen (Lortab) D. Acetaminophen (Tylenol)

*D. Acetaminophen (Tylenol)* This is the best choice, because acetaminophen (Tylenol) is a non-opioid analgesic, and it will not cause CNS depression.

The day after Jeff was transferred to the Surgical Unit, he becomes very irritable. The UAP reports to the nurse that Jeff requests that the drapes and door be closed and the lights turned out because of a severe headache. He also requested to be left alone. Which intervention should the nurse initiate? A. Postpone going to Jeff's room for one hour. B. Instruct the UAP to leave him alone for a few hours. C. Administer an analgesic for his headache. D. Assess vital signs and neurological status.

*D. Assess vital signs and neurological status.* Jeff is exhibiting symptoms of meningitis, a serious complication requiring immediate medical and nursing intervention. The nurse should gather additional assessment data, such as vital signs and neurologic status, and then notify the healthcare provider

This method of administration is chosen to reduce the risk of which possible problem? A. Medication error. B. Allergic reaction. C. Extravasation. D. Fluid overload.

*D. Fluid Overload* The client with increased ICP requires very careful administration of IV fluids to avoid fluid volume overload, which would increase ICP. Using an infusion pump will reduce the risk of fluid overload.

The nurse takes Jeff's vital signs and notes that he has a fever of 102° F (38.9° C), and that he reports pain upon flexion of his neck (nuchal rigidity). The HCP is notified, and it is determined that Jeff has meningitis. Jeff is exhibiting the three classic manifestations of meningitis: fever, headache, and nuchal rigidity. In addition, he manifests irritability and photophobia, which are common symptoms of meningitis. Which additional clinical manifestation is often seen in bacterial meningitis? A. Diarrhea. B. Muscle pain. C. Confusion. D. Photophobia.

*D. Photophobia* Photophobia is a sign of bacterial meningitis.