M.11-3: Exemplar: Traumatic Brain Injury

A client presents with an altered level of consciousness resulting from a traumatic brain injury​ (TBI). The MRI results show a large intracranial hemorrhage with a hematoma formation. Which collaborative intervention should the nurse​ anticipate? A. Surgical evacuation B. Antiseizure medication C. Vasoactive medication D. Transcranial Doppler

A. Surgical evacuation

Which intervention should the nurse include in the plan of care for a client with a history of traumatic brain injuries​ (TBIs) to determine worsening of the​ situation? (Select all that​ apply.) A. Asking the client to state their name and date of birth B. Assessing​ short- and​ long-term memory changes C. Assessing for new onset​ self-care deficits D. Determining the​ client's level of orientation E. Reviewing the transcranial Doppler results

A,B,C,D

Which information regarding postconcussion syndrome and signs to report should the nurse provide to the client who sustained a​ concussion? (Select all that​ apply.) A. Personality changes B. Nausea C. Rash or hives D. Sensitivity to light and noise E. Insomnia

A,B,D,E

Which parameter should the nurse assess when administering pain medication to a client with a traumatic brain injury​ (TBI)? (Select all that​ apply.) A. Heart rate B. Pain level C. White blood cell count D. Respirations E. Bowel sounds

A,B,D,E

The school nurse is teaching a group of​ high-school football players about ways to prevent concussions and traumatic brain injuries​ (TBIs). Which information should the nurse include in this​ discussion? (Select all that​ apply.) A. Avoiding tackling headfirst B. Having a sports physical every other year C. Notifying the coach or other adult of head injury D. Playing without adults E. Making sure the helmet is fitted based on head size

A,C,E

The home health nurse is working with a family of a​ 10-year-old child who suffered a moderate traumatic brain injury​ (TBI). Which information should the nurse provide to the parents to help them understand the changes that may occur due to this​ injury? (Select all that​ apply.) A. Increased lethargy B. Increased appetite C. Less communicative D. Requires less sleep E. No interest in favorite toys

A,E

The nurse is assigning an unlicensed assistive personnel​ (UAP) to care for a client who has a traumatic brain injury​ (TBI). The nurse explains the severity of the injury. Which aspect of the plan of care can the nurse delegate to the​ UAP? A. Obtaining vital signs every 15-30 minutes B. Gathering assessment information for the Glasgow Coma Scale C. Administering pain medication D. Obtaining the signatures of the family for consent to treat

A. Obtaining vital signs every 15-30 minutes

The nurse is working with a client who sustained a traumatic brain injury​ (TBI) and is experiencing decreased mobility and decreased fluid intake. Which medication should the nurse expect the healthcare provider to​ prescribe? A. Stool softener B. Vasoactive medication C. H2 receptor antagonist D. Proton pump inhibitor

A. Stool softener

The nurse is caring for an adolescent who presents with​ headache, memory​ loss, and blurred vision after sustaining an injury playing football. The healthcare provider diagnoses the client with a concussion and instructs the client to refrain from sports for a minimum of 4 weeks to prevent second impact syndrome​ (SIS). Which client statement indicates an understanding of the instructions​ provided? A. ​"I should stay away from any type of sports activity for a​ month." B. ​"I should avoid playing all sports until the headaches​ dissipate." C. ​"I should be out on the field with my teammates but not​ participate." D. ​"I should refrain from going to school until my symptoms go​ away."

A. ​"I should stay away from any type of sports activity for a​ month."

Which types of sports are most likely to cause concussion and traumatic brain​ injury? A. ​High-impact B. Energetic C. Competitive D. Team

A. ​High-impact

A patient with a traumatic brain injury (TBI) is diagnosed as being brain dead. Which assessment finding supports this diagnosis? A.Absence of spontaneous respirations B.Complete unawareness of self C.Awareness of environment but inability to communicate D.Extended neck and clenched jaw

A.Absence of spontaneous respirations Brain death is the cessation and irreversibility of all brain functions, including the brainstem. Since the brainstem controls respirations, absence of respirations would be a nursing assessment finding in brain death. Complete unawareness of self describes a persistent vegetative state. An extended neck with clenched jaw describes decerebrate posturing. Awareness of the environment but inability to communicate describes locked-in syndrome.

The nurse is working with the parents of an infant with croup who cries constantly. The parents are very frustrated. Which intervention would be most appropriate to prevent shaken baby syndrome and a subsequent traumatic brain injury (TBI)? A.Asking someone to watch the baby when overwhelmed B.Taking the infant to a healthcare facility for treatment C.Removing toys and clutter from the floor and hallways D.Using seat belts and car safety seats when in a motor vehicle

A.Asking someone to watch the baby when overwhelmed Traumatic brain injuries (TBIs) in infants are frequently the result of shaken baby syndrome. Therefore, the frustrated parents should enlist a person as a designated backup for help in case they are feeling overwhelmed. This allows the parents time away and prevents child abuse. Toys and clutter are not the main reasons for TBIs in infants. Using seat belts and car safety seats in a moving vehicle is essential. However, this will not prevent shaken baby syndrome. The parents should be encouraged to bring the infant in for medical treatment if the baby is inconsolable with the croup, but this will not prevent shaken baby syndrome.

The nurse is working with the family of a patient who is on life support due to a severe traumatic brain injury (TBI). The healthcare provider informs the family that the patient has very little brain function and has little to no hope of survival. Which member of the healthcare team should the nurse include in the plan of care to meet the family's needs? A.Chaplain B.Psychiatrist C.Surgeon D.Psychologist

A.Chaplain The family is dealing with possible end-of-life issues with the patient. Therefore, the nurse would refer the patient's family to the hospital chaplain. A psychologist and psychiatrist would be beneficial for short- and long-term counseling later, but the immediate need is for a chaplain. The surgeon would be included in the plan of care if surgery were necessary for the treatment.

The nurse is working with the family of a patient who sustained a traumatic brain injury (TBI). The nurse is sitting in the room with the patient listening to the patient talk through the injury. Which nursing diagnosis does this intervention support? A.Coping, Ineffective B.Memory, Impaired C.Self-care, Readiness for Enhanced D.Knowledge, Deficient

A.Coping, Ineffective The patient is demonstrating ineffective individual coping and the nurse is allowing the patient to verbalize their feelings. The patient is recalling the event, so there is no evidence of impaired memory. The nurse is not providing teaching, so a nursing diagnosis of Knowledge, Deficient is not applicable. There is no evidence that the patient is unable to perform daily care activities, including self-care, so the nurse is not addressing a readiness for enhanced self-care at this time. (NANDA-I ©2014

The nurse includes the assistance of the social worker when planning care for a patient who has physical limitations resulting from a traumatic brain injury (TBI). Which intervention would the social worker provide? A.Home modifications B.Home health therapy visits C.Home medication monitoring D.A home exercise program

A.Home modifications The social worker would be able to provide the patient and the family with resources for home modifications that are needed to meet physical needs. The physical and occupational therapists would develop a home exercise program. Home medication monitoring would be provided by a skilled nurse.

The nurse is developing a plan of care for the family of a war veteran who sustained a moderate traumatic brain injury (TBI). The patient is experiencing verbal and language impairment. Which intervention would be most appropriate for the nurse to include? A.Providing a dry erase board and a marker B.Orienting the patient to person, place, and time C.Providing information about hearing aids D.Administering medications as prescribed

A.Providing a dry erase board and a marker The patient is experiencing difficulty with speech and language; therefore, the nurse would provide a dry erase board and marker to help the patient communicate. The patient who is confused would need to be reoriented to person, place, and time. The nurse would not administer medications to correct speech and language deficits. Medications may be used to treat seizures or manage pain. The patient does not have a hearing problem, so a hearing aid would not be needed.

The nurse is caring for a client who reports being hit over the head by their significant other. Which assessment finding should lead the nurse to suspect that the client has a skull​ fracture? (Select all that​ apply.) A. Loss of consciousness B. Clear drainage from the nares C. Raccoon eyes D. Battle sign E. Dysphagia

B,C,D

Traumatic brain injury occurs when which of the following causes some degree of impairment to brain structure or​ function? A. Stress reaction B. External force C. Congenital disorder D. Infection

B. External force

Which statement about cerebral edema or ischemia is​ true? A. It often causes a skull fracture. B. It is often secondary to a traumatic brain injury. C. It is an example of a penetrating injury. D. It is an example of a lacerating injury.

B. It is often secondary to a traumatic brain injury.

The nurse is developing a plan of care for a client who sustained a traumatic brain injury​ (TBI). The client is having difficulty with meeting​ self-care needs, including​ dressing, bathing, and grooming. Which member of the healthcare team would help the client master these​ tasks? A. The physical therapist​ (PT) B. The occupational therapist​ (OT) C. The unlicensed assistive personnel​ (UAP) D. The hospital chaplain

B. The occupational therapist​ (OT)

The nurse is providing a presentation to a group of​ high-school-aged children and their parents regarding safety and traumatic brain injury​ (TBI) prevention. Which information would be most appropriate to provide to this age​ group? A. Clearing the floor of cords B. Using seat belts C. Being cognizant of​ sensory-perceptual changes D. Spotting for signs of shaken baby syndrome

B. Using seat belts

The nurse is caring for an older adult client who sustained a traumatic brain injury​ (TBI) who is schedule to be transferred to a rehabilitation center after the acute phase of care is completed. The client asks the nurse what will be done for them there that cannot be done in a hospital. Which response by the nurse is most ​accurate? A. ​"The rehabilitation phase after a traumatic brain injury​ (TBI) will cure cognitive​ deficits." B. ​"You will have different therapies tailored to meet your specific​ needs." C. ​"This healthcare facility will make the determination if you are safe to live​ alone." D. ​"You seem concerned about transitioning to a new healthcare facility for​ treatment."

B. ​"You will have different therapies tailored to meet your specific​ needs."

The healthcare provider ordered a computerized tomography (CT) scan for a patient admitted with a possible traumatic brain injury (TBI). The family wants to know about the purpose of this test. Which response by the nurse is accurate? A.A CT scan is a diagnostic test that the healthcare provider will prescribe for all patients." B."A CT scan will determine the presence and location of any fractures of the skull or bleeding in the brain." C."A CT scan will help determine the presence of hearing or language difficulties related to the injury." D."A CT scan is used to determine the presence of tumors or abnormal growths that caused the problem."

B."A CT scan will determine the presence and location of any fractures of the skull or bleeding in the brain." The patient possibly sustained a traumatic brain injury (TBI), and a CT scan will show any areas of bleeding inside or outside of the skull, any fractures, or other brain damage. The healthcare provider will not arbitrarily prescribe a CT scan for all patients admitted to the hospital, as this is an expensive test and is not necessary for everyone. Hearing and language difficulties are determined by audiologists and speech therapists. Tumors and growths can be detected by a CT scan; however, this patient is being evaluated for a TBI, not a malignancy.

Which patient should the nurse consider to be at highest risk for developing a traumatic brain injury (TBI)? A.A 26-year-old patient who uses a seat belt B.A 2-year-old child of an alcoholic parent C.A 14-year-old patient on the school tennis team D.A 50-year-old patient who is a maintenance worker

B.A 2-year-old child of an alcoholic parent The patient at highest risk for sustaining a TBI is the 2-year-old child who has an alcoholic parent. The parent may be abusive during alcoholic binges and cause a TBI to the child. The patient wearing a seat belt in the car has a lower risk for developing a TBI if a motor vehicle crash occurs. Tennis is not considered a contact sport and has a low incidence of TBI. Maintenance workers are not at risk for traumatic brain injuries.

Which older adult would be at increased risk for intracranial hemorrhage after sustaining a fall? A.A patient with a prior history of Alzheimer-type dementia B.A patient taking anticoagulant medication for atrial fibrillation C.A patient with osteoporosis who sustained a hip fracture D.A patient with a history of Parkinson disease

B.A patient taking anticoagulant medication for atrial fibrillation The older adult is at higher risk for falls and traumatic brain injuries (TBIs) due to sensory or perceptual deficits. The patient that is at highest risk for an intracranial hemorrhage is the person taking anticoagulants, because this increases the risk for bleeding. A history of TBIs as a child or young adult can increase the risk for dementia later in life. Osteoporosis is not a risk factor for intracranial hemorrhage; it is caused by loss of calcium in the bones. Parkinson disease can lead to an increased risk for falls, but it does not lead directly to intracranial hemorrhage.

The nurse is teaching a group of adults about ways to prevent traumatic brain injuries (TBIs) in all age groups. Which nursing intervention would be most important to decreasing the risk for traumatic brain injury in people over the age of 65? A.Suggesting a reduction in activity B.Conducting a home safety assessment C.Restricting movement with chemical restraints D.Preventing participation in contact sports

B.Conducting a home safety assessment The nurse should teach all patients about ways to prevent head injuries or trauma. For older adult patients, prevention is focused on reducing the risk for injury by conducting a home safety assessment. Older adult patients do not need to reduce activity, avoid participation in contact sports, or have movement restricted with chemical restraints.

The nurse is caring for a patient who fell and sustained a hematoma. The nurse notes that the patient is taking an anticoagulant for a history of pulmonary emboli. Which nursing assessment should be a priority? A.Appetite B.Mental status C.Fluid volume D.Hearing

B.Mental status A patient taking an anticoagulant is at increased risk for bleeding, as evidenced by a hematoma. This includes bleeding into the brain. Therefore, the nurse would assess the patient's mental status. Appetite and fluid volume would not be a factor in intracranial bleeding. Hearing would be assessed in a patient with sensorineural deficits.

Which factor increases the risk of an older adult patient developing a traumatic brain injury (TBI)? A.Motor vehicle crash B.Polypharmacy C.Being a victim of violence D.Physical abuse

B.Polypharmacy Older adult patients are at higher risk for developing traumatic brain injuries (TBIs) due to polypharmacy, the use of multiple prescriptions and over-the-counter medications, and changes in sensory/perception with aging. Motor vehicle crashes affect younger people more than they do older adults. Physical abuse is one of the main causes of TBI in children under the age of 4. Violence affects adolescents related to gang activity.

Which nursing diagnosis would be most appropriate for a patient who needs assistance with personal care? A.Hopelessness B.Self-care Deficit, Bathing C.Grieving D.Health Maintenance, Ineffective

B.Self-care Deficit, Bathing The patient requiring assistance with personal care indicates a self-care deficit, which may include bathing, dressing, feeding, or toileting. The patient who smokes, drinks, or has maladaptive health patterns indicates an alteration in health maintenance. Hopelessness is manifested by depression and statements regarding poor prognosis and health status. Grieving may be occurring due to loss of independence, but this is not manifested by an inability to bathe oneself or provide self-hygiene. (NANDA-I ©2014)

The nurse is caring for a patient admitted to a rehabilitation facility after sustaining a traumatic brain injury (TBI). The patient is withdrawn and refuses to leave the room. Which initial intervention would the nurse make to help the patient? A.Giving the patient books to read on their own B.Spending time with the patient in their room each day C.Arranging for the patient to attend a group activity D.Assigning a roommate to the patient's room

B.Spending time with the patient in their room each day The patient is having difficulty coping with changes that have occurred from the injury. The nurse's initial intervention would be to set aside time to spend with the patient in their room. Eventually, the nurse would progress to one-on-one activities out of the room, but not a group activity. Assigning a roommate may not help the patient who is depressed. The patient needs to progress through the depression at their own pace. Providing books to read further isolates the patient from the nurse and others.

The nurse assesses a respiratory rate of 8 breaths/min in a patient with a traumatic brain injury. Shortly thereafter, the patient begins hiccupping. Which part of the brain should the nurse suspect is being affected in this patient? A.The cerebellum B.The brainstem C.The thalamus D.The occipital lobe

B.The brainstem The brainstem controls breathing and regulates hiccupping. The thalamus is the relay center for all information coming into the brain. The cerebellum is responsible for muscle movement, balance, and control. The occipital lobe contains the visual cortex to process vision.

The nurse is preparing a client for surgery as a result of a traumatic injury. Which assessment finding indicates a need for the nurse to notify the healthcare​ provider? A. Reporting constant headaches B. Bloody drainage from the nares C. A change in level of consciousness D. An unchanged repeat Glasgow Coma Scale rating

C. A change in level of consciousness

Which clinical manifestation is associated with a mild​ concussion? A. Difficulty breathing B. Bleeding in the brain C. Acute headache D. Prolonged unconsciousness

C. Acute headache

A nurse is planning a teaching exercise on prevention of traumatic brain injury and identifying examples of people with a higher risk of TBI. Which of the following people is not in a​ higher-risk group for a​ TBI? A. A​ 77-year-old retiree B. A​ 2-year-old child C. A​ 44-year-old office worker D. A​ 13-year-old adolescent

C. A​ 44-year-old office worker

Which of the following infant clients presenting with traumatic brain injury​ (TBI) is least likely the victim of child​ abuse? A. Infant with diffuse axonal​ injury, unknown cause B. Infant with contusion sustained from fall from high chair C. Infant with diffuse axonal injury following involvement as passenger in a vehicle collision D. Infant with​ contusion, unknown cause

C. Infant with diffuse axonal injury following involvement as passenger in a vehicle collision

A client presents with a head injury after being in a motor vehicle accident and is diagnosed with a brain contusion with a​ coup-contrecoup injury. The client is stabilized and sent​ home, but the healthcare provider instructs the client to return in 3 days for a repeat MRI. Which explains the rationale for a repeat​ MRI? A. It is protocol for all MRIs to be repeated in traumatic brain injuries​ (TBIs). B. The MRI will be repeated to determine the cause of the​ client's injuries. C. It can take hours to days for contusions to form from a​ coup-contrecoup injury. D. The MRI can determine the grade of concussion that the client sustained.

C. It can take hours to days for contusions to form from a​ coup-contrecoup injury.

The nurse is reviewing the plan of care for a client brought in to the emergency department after a motorcycle accident. The healthcare provider suspects that the client has a diffuse axonal injury. Which test should the nurse anticipate being prescribed to confirm this​ diagnosis? A. Cerebrospinal fluid​ (CSF) analysis B. Transcranial Doppler C. MRI scan D. CT scan

C. MRI scan

A client presents with a mild concussion following a fall. Which nursing diagnosis is least likely to be made for this​ client? A. Acute Confusion B. Acute Pain C. Risk for​ Post-Trauma Syndrome D. Nausea

C. Risk for​ Post-Trauma Syndrome

The nurse is caring for a client who is 36 weeks pregnant and sustained head trauma from a physical assault. The nurse initiated fetal​ monitoring, which shows that the fetus is healthy and​ viable, but the​ mother's condition is deteriorating. Which should the nurse prepare to perform next​? A. Administering medication to induce labor B. Coordinating pastoral care services C. Scheduling a cesarean birth D. Reporting the situation to the hospital ethics board

C. Scheduling a cesarean birth

The nurse is developing a plan of care for a client with a traumatic brain injury​ (TBI) who sustained auditory damage. Which outcome is most appropriate for this​ client? A. The client will use assistive devices for walking. B. The client will remain free of injury. C. The client will wear hearing aids. D. The client will verbalize understanding of signs to report.

C. The client will wear hearing aids.

A client is classified as Grade 4 for risk of cerebral vasospasm because of intracerebral clotting and absence of blood in the basal cisterns. Which diagnostic test is most useful to assess intracerebral hemorrhage and grade cerebral​ vasospasms? A. CT scan B. Cerebrospinal fluid​ (CSF) analysis C. Transcranial Doppler D. MRI

C. Transcranial Doppler

The nurse is caring for an adult patient who sustained multiple injuries in an all-terrain vehicle (ATV) accident. Which clinical finding warrants immediate healthcare provider notification? A.Bruising to the lower extremities B.Alert and oriented to place and situation C.Clear fluid from the patient's nose D.Reports of muscular pain in the arms

C.Clear fluid from the patient's nose Clear drainage from the nose or ears can indicate a cerebrospinal fluid leak. This warrants immediate healthcare provider notification, as this indicates a basilar skull fracture. Bruising and muscle pain are normal findings after sustaining an ATV accident and do not require notification. Alert and oriented to place and situation would be a normal finding.

The nurse is caring for a soldier who experienced a traumatic brain injury (TBI) from a roadside bomb, resulting in auditory damage. Which intervention would be most appropriate for the nurse to incorporate in the plan of care? A.Limiting available choices for decision making B.Promoting independence with daily self-care C.Facing the patient and speaking clearly D.Providing frequent orientation to time and place

C.Facing the patient and speaking clearly The nurse should face the person and speak clearly for a patient that has experienced a traumatic brain injury with auditory deficits. Promoting independence with self-care would be appropriate for patients who have physical or cognitive deficits. Limiting choices would be appropriate for patients with poor judgment. The nurse would provide frequent orientation to time and place for a patient with cognitive deficits or memory problems

The school nurse is teaching a group of adolescent students regarding the incidence of traumatic brain injuries (TBI). Which sport should the nurse include in the presentation as an example that causes a high incidence of concussions and TBIs? A.Swimming B.Bicycling C.Hockey D.Jogging

C.Hockey Sports such as hockey, football, and boxing have a high rate of concussions and TBIs due to head trauma. Swimming, bicycling, and jogging have low rates due to lack of direct head contact.

A patient experiences fractures of the left leg and a traumatic brain injury (TBI). Which assessment finding indicates increased intracranial pressure (IICP)? A.Oliguria B.Nausea C.Irritability D.Hypotension

C.Irritability Irritability may indicate that the patient is experiencing an increase in intracranial pressure, especially if associated with additional signs of bradycardia, increased systolic pressure, increased pulse pressure, vomiting, headache, lethargy, and change in mental status. Nausea does not accompany the vomiting associated with IICP. Hypotension and oliguria are not associated with IICP.

An adolescent who wants to play baseball is seen at the clinic for a pre-sports physical. Which information should the nurse provide the adolescent that helps prevent traumatic brain injuries (TBIs)? A.Refrain from tackling other players on the field. B.Wear your helmet when you are a pitcher. C.Refrain from sliding into the base headfirst. D.Notify the coach if you are feeling overtired.

C.Refrain from sliding into the base headfirst. Children and adolescents who play baseball should be instructed to refrain from sliding into the base headfirst, because this could lead to aTBI. Baseball players usually do not wear helmets unless at bat. Tackling is a component of football, not baseball. Feeling overtired can be caused by a multitude of problems, including lack of sleep. This is not a sign of a concussion

A patient with a traumatic brain injury (TBI) is intubated and placed on mechanical ventilation. Which information should the nurse use to evaluate the effectiveness of this respiratory intervention? A.Motor and sensory function B.Cranial nerve function C.Glasgow Coma Scale score D.Arterial blood gas results

D.Arterial blood gas results A patient with an alteration in level of consciousness (LOC) may be unable to maintain an open airway and engage in spontaneous respirations. The patient may need endotracheal intubation or mechanical ventilation. Arterial blood gases are used to guide the effectiveness of ventilation. Glasgow Coma Scale score, cranial nerve function, and motor and sensory function are used to determine the effect of intracranial pressure on body functioning.

The nurse is teaching a child and their parents about postconcussion instructions prior to discharge. Which information should the nurse include in the teaching? A.Instructing that drowsiness is normal for the first few days B.Allowing continuous sleep for the first 12 hours C.Refraining from sports for at least 7-10 days D.Taking ibuprofen as directed on the bottle

C.Refraining from sports for at least 7-10 days The nurse would instruct the patient and family to refrain from sporting activities for a minimum of 7-10 days after a concussion. This prevents second injury syndrome (SIS). Ibuprofen and other nonsteroidal anti-inflammatory drugs are contraindicated, as they can cause intracranial hemorrhage. The child should not be allowed to sleep continuously for the first 12 hours. The family should wake the child every 2-3 hours to determine changes in manner or actions. Increased drowsiness is understandable for the first day, but chronic sleepiness needs to be reported.

The nurse is caring for a patient admitted to the hospital with brainstem damage resulting from a traumatic brain injury. Which assessment finding warrants immediate healthcare provider notification? A.Slurred speech B.Constipation C.Repetitive hiccupping D.Diarrhea

C.Repetitive hiccupping The brainstem is responsible for breathing, blood pressure, and pulse. Damage to the brainstem can lead to repetitive hiccupping, sneezing, or coughing. Therefore, this finding can indicate further damage and warrants immediate healthcare provider notification. Slurred speech can indicate cerebellar damage. Diarrhea and constipation are not related to brainstem damage.

The nurse is teaching a group of adolescents on how to decrease the risk of traumatic brain injuries (TBIs). Which information is most appropriate to provide to this age group? A.Refraining from participating in all sports B.Decreasing the amount of alcohol ingested C.Wearing a helmet when skateboarding D.Keeping pathways clear and free of cords

C.Wearing a helmet when skateboarding Adolescents are risk takers. At their developmental age level, they believe that they are invincible and that nothing can hurt them. Therefore, they tend to ride bikes and skateboards as well as participate in contact sports without the use of helmets. The nurse should instruct the adolescent on the importance of safety headgear. Adolescents should be eliminating alcohol and drug consumption, not just decreasing it. The nurse would not instruct the adolescent to refrain from participating in all sports. Appropriate safety precautions minimize the risk of TBIs. Removing cords from pathways minimizes falls in the older adult population.

An emergency room nurse receives a client with a head injury. Which intervention is the priority in the care of this​ client? A. Determining the need for urination B. Administering pain medication C. Placing the client in a​ side-lying position D. Obtaining a baseline Glasgow Coma Scale assessment

D. Obtaining a baseline Glasgow Coma Scale assessment

A client is seen in the urgent care center with signs of a mild traumatic brain injury​ (TBI). Which clinical manifestation would indicate a need to see a​ neurologist? A. Raccoon eyes B. Tinnitus C. Irritability D. Unequal pupils

D. Unequal pupils

The school nurse is teaching a group of adolescent athletes about reducing the risk for sustaining traumatic brain injuries​ (TBI). To provide​ client-centered education to this​ population, which information is most appropriate for the school nurse to include in the teaching​ session? A. ​"A fall from even a low height can cause traumatic brain​ injury." B. ​"A traumatic brain injury can occur to anyone from a wide range of​ causes." C. ​"Wearing seat belts can protect against injuries in motor vehicle​ collisions." D. ​"If you are injured in a game or​ practice, don't play through the​ pain."

D. ​"If you are injured in a game or​ practice, don't play through the​ pain."

Which class of medication should the nurse expect to administer to a patient with seizures related to a traumatic brain injury (TBI)? A.Stool softener B.Vasoactive medication C.H2-receptor antagonist D.Antiseizure

D.Antiseizure The patient experiencing seizures due to TBI would benefit from an anticonvulsant. H2-receptor antagonists decrease gastric acid production in patients with TBIs. Stool softeners prevent straining with bowel movements, which can increase intracranial pressure. Vasoactive medications are used to keep the patient hemodynamically stable.

A female patient who is unresponsive after sustaining injuries in a motor vehicle crash is brought to the emergency department. Laboratory results indicate that the patient is pregnant. Once the patient is stabilized, which intervention should the nurse perform next? A.Administering anticonvulsant medications B.Preparing for imminent miscarriage C.Administering oxygen via nasal cannula D.Placing a fetal monitor on the patient

D.Placing a fetal monitor on the patient Once the nurse determines that a patient with a traumatic brain injury (TBI) is pregnant, the next intervention the nurse should perform is to initiate fetal monitoring to determine the status of the fetus. The nurse would not assume that the patient will miscarry the baby, so the nurse would not prepare for this. The nurse would administer anticonvulsants if the patient were having a seizure. Oxygen would be administered if the patient were hypoxic.

The nurse is working with a veteran who experienced a traumatic brain injury (TBI) related to combat. The patient has made progress and is medically stable but needs further extensive physical and occupational therapy. From which type of facility would the patient get the most benefit? a.A rehabilitation center b.An outpatient center c.A nursing home d.Home health service

a.A rehabilitation center This patient who needs further physical and occupational inpatient care would benefit most from a rehabilitation center. A nursing home would not provide therapy for the patient. An outpatient center would not provide extensive therapy. Home health services may be beneficial when the patient is discharged from the rehabilitation facility.