Traumatic Brain Injury

An unconscious client arrives in the emergency department following a fall that resulted in a severe head injury. Which action does the nurse take first? 1. Assess the patency of the airway. 2. Check the client's pupils for size and reaction to light. 3. Establish the clien'ts LOC 4. evaluate the client's motor response

1. Assess the patency of the airway.

The nurse performs an assessment for a client reporting severe headaches and new onset of seizure activity. At the begining of the shift, the client is talking with family and VS are WNL. 6 hours later, the nurse finds the client difficult to rouse and unable to speak coherently. The systolic BP is elvated, pulse pressure is widening, and the client has bradycardia. Which is the most correct interpretation of these findings? 1. Increasing ICP 2. recent tonic clonic seizure activity 3. phenytoin toxicity 4. severe hypertension

1. Increasing ICP

The nurse provides care for a newly admitted client dx with a head injury. The nurse notes the client has clear drainage. Which action does the nurse take first? 1. Obtains a specimen of the fluid for culture & sensitivity 2. Checks the nasal draiange for gluocse 3. Obtains the client's tempt 4. instructs client to blow nose.

2. Checks the nasal draiange for glucose

A client who had a severe traumatic brain injury is being discharged home, where the spouse will be a fulltime caregiver. What statement by the spouse would lead the nurse to provide further education on home care? a. I know I can take care of all these needs by myself. b. I need to seek counseling because I am very angry. c. Hopefully things will improve gradually over time. d. With respite care and support, I think I can do this

ANS: A This caregiver has unrealistic expectations about being able to do everything without help. Acknowledging anger and seeking counseling show a realistic outlook and plans for accomplishing goals. Hoping for improvement over time is also realistic, especially with the inclusion of the word hopefully. Realizing the importance of respite care and support also is a realistic outlook.

A nurse is caring for four clients in the neurologic intensive care unit. After receiving the hand-off report, which client should the nurse see first? a. Client with a Glasgow Coma Scale score that was 10 and is now is 8 b. Client with a Glasgow Coma Scale score that was 9 and is now is 12 c. Client with a moderate brain injury who is amnesic for the event d. Client who is requesting pain medication for a headache

ANS: A A 2-point decrease in the Glasgow Coma Scale score is clinically significant and the nurse needs to see this client first. An improvement in the score is a good sign. Amnesia is an expected finding with brain injuries, so this client is lower priority. The client requesting pain medication should be seen after the one with the declining Glasgow Coma Scale score.

A client is in the clinic for a follow-up visit after a moderate traumatic brain injury. The clients spouse is very frustrated, stating that the clients personality has changed and the situation is intolerable. What action by the nurse is best? a. Explain that personality changes are common following brain injuries. b. Ask the client why he or she is acting out and behaving differently. c. Refer the client and spouse to a head injury support group. d. Tell the spouse this is expected and he or she will have to learn to cope.

ANS: A Personality and behavior often change permanently after head injury. The nurse should explain this to the spouse. Asking the client about his or her behavior isnt useful because the client probably cannot help it. A referral might be a good idea, but the nurse needs to do something in addition to just referring the couple. Telling the spouse to learn to cope belittles the spouses concerns and feelings

A client has an intraventricular catheter. What action by the nurse takes priority? a. Document intracranial pressure readings. b. Perform hand hygiene before client care. c. Measure intracranial pressure per hospital policy. d. Teach the client and family about the device.

ANS: B All of the actions are appropriate for this client. However, performing hand hygiene takes priority because it prevents infection, which is a possibly devastating complication.

A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit, sedated and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time? a. Inability to communicate b. Nutritional deficit c. Risk for acquiring an infection d. Risk for skin breakdown

ANS: C The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a skin breakdown, but it is not the immediate danger a brain infection would be.

The nurse performs a neurological assessment of a client dx iwth a severe TBI. Which indicates the nurse correctly analyzes a GCS score of 3. 1. The client is at high risk for infection 2. The client is able to follow commands 3. The client is totally dependent for all care 4. The client's pupils are fixaed and dilated.

3. The client is totally dependent for all care

A client who had therapeutic hypothermia after a traumatic brain injury is slowly rewarmed to a normal core temperature. For which assessment finding would the nurse monitor during the rewarming process? a. Cardiac dysrhythmias b. Loss of consciousness c. Nausea and vomiting d. Fever

ANS: A Due to fluid and electrolyte changes that typically occur during the rewarming process, the nurse monitors for cardiac dysrhythmias. The other findings are not common during this process.

The nurse assesses a client who has a mild traumatic brain injury (TBI) for signs and symptoms consistent with this injury. What signs and symptoms does the nurse expect? (Select all that apply.) a. Sensitivity to light and sound b. Reports "feeling foggy" c. Unconscious for an hour after injury d. Elevated temperature e. Widened pulse pressure

ANS: A, B A mild TBI would possibly lead to sensitivity to light and sound and a feeling of mental fogginess. The patient would have been unconscious for less than 30 minutes. An elevated temperature is not related. A widened pulse pressure is indicative of increased intracranial pressure, not a mild TBI.

The nurse is caring for a client with increasing intracranial pressure (ICP) following a stroke. Which evidence-based nursing actions are indicated for this client? (Select all that apply.) a. Hyperoxygenate the client before and after suctioning. b. Avoid sudden or extreme hip or neck flexion. c. Provide oxygen to maintain an SaO2 of 95% or greater. d. Maintain the client in a supine position at all times. e. Avoid clustering care nursing activities and procedures. f. Provide environmental stimulation to improve cognition.

ANS: A, B, C, E These precautions help prevent further increases in ICP. Clustering nursing activities and procedures and providing stimulation can increase ICP and should be avoided.

A clients mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the clients cerebral perfusion pressure, what should the nurse anticipate for this client? a. Impending brain herniation b. Poor prognosis and cognitive function c. Probable complete recovery d. Unable to tell from this information

ANS: B The cerebral perfusion pressure (CPP) is the intracranial pressure subtracted from the mean arterial pressure: in this case, 60 20 = 40. For optimal outcomes, CPP should be at least 70 mm Hg. This client has very low CPP, which will probably lead to a poorer prognosis with significant cognitive dysfunction should the client survive. This data does not indicate impending brain herniation or complete recovery.

A client who is experiencing a traumatic brain injury has increasing intracranial pressure (ICP). What drug will the nurse anticipate to be prescribed for this client? a. Phenytoin b. Lorazepam c. Mannitol d. Morphine

ANS: C Increased intracranial pressure is often the result of cerebral edema as a result of traumatic brain injury. Therefore, as osmotic diuretic such as mannitol or a loop diuretic like furosemide is administered. The other drugs are not appropriate to manage increasing ICP.

A client with a severe traumatic brain injury has an organ donor card in his wallet. Which nursing action is appropriate? a. Request a directive form the client's primary health care provider. b. Ask the family if they agree to organ donation for the client. c. Wait until brain death is determined before acting on organ donation. d. Contact the local organ procurement organization as soon as possible.

ANS: D The appropriate nursing action is to respect the client's desire to be an organ donor and contact the local organ procurement organization even if family members do not agree. In most agencies, the primary health care provider does not have to write an order or directive to approve the organ donation. Family consent is not required.

The nurse is caring for four clients with traumatic brain injuries. Which client should the nurse assess first? a. Client with cerebral perfusion pressure of 72 mm Hg b. Client who has a Glasgow Coma Scale score of 12 c. Client with a PaCO2 of 36 mm Hg who is on a ventilator d. Client who has a temperature of 102 F (38.9 C)

ANS: D A fever is a poor prognostic indicator in clients with brain injuries. The nurse should see this client first. A Glasgow Co

The nurse provides care for a client admitted to the emergency department following an autoobile accident. The client reports dizziness, and th health care provider suspects a head injury. The nurse intervenes if which activity is observed? 1. The client is placed in trendelenburg position. 2. the clien'ts neck is immobilized prior to being X-rayed 3. The nursing staff frequently monitors the client's level of consciousness. 4. The nursing staff observes for seizures.

1. The client is placed in trendelenburg position.

The nurse assesses for signs associated with IICP in a client diagnosed with a subdural hematoma. Which is the earliest sign of an increase in ICP? 1. a change in LOC 2. a widening pulse pressure 3. bradycardia 4. decorticate position

1. a change in LOC

The nurse provides care for a client diagnosed with a closed head injury and IICP. Whichaction by the nurse is best? 1. Position the clinet with head of bed flat and cleint's head in a neutral positon. 2. Instruct client to exhale when turning or moving in bed. 3. Encourage client to cough and deep breathe every two hours. 4. Suciton client frequently and hyperoxygenate prior to suctioning.

2. Instruct client to exhale when turning or moving in bed.

The nurse provides care for a client dx with severa TBI. The client has been placed on a FR. The client has an intraventricular monitor in place and the ICP reading is 25 mm Hg. What is the rationale for the FR? 1. to decrease cerebral edema. 2. to decrease peripheral edema 3. to decrease the need for suctioning 4. to decrease the risk for respiratory complications

1. to decrease cerebral edema.

The nurse cares for a client with IICP. Which activities contribute to IICP? (Select all that apply) 1. A quiet enviorment 2. Hand restraints 3. Having a bowel movement 4. Listening to soft music 5. Watching television

2. Hand restraints 3. Having a bowel movement

The nurse provides care for a client dx with IICP as the result of a closed head inury. The client is unconscious with an intracranial pressure monitoring device in place. Which is the most appropriate position for the nurse to place this client after perfoming nursing care activities? 1. High-fowlers 2. Semi-Fowlers 3. Right lateral recumbent 4. Supine

2. Semi-Fowlers

Which should the nurse include in the plan of care for a cient dx with ICP? 1. Frequently suciton the airway 2. Teach the client to avoid the Valsalva maneuver 3. Position the client supine in a dark room 4. Withold sedatives when the ICP is greater than 20 mm Hg

2. Teach the client to avoid the Valsalva maneuver

The nurse provides care for a school-age client with a TBI. Which symptoms best indicate IICP? 1. Headache, cring, sensitivity to loud noises and bright lights. 2. Widening pulse pressure, slowed respirations, bradycardia. 3. Hypotension, cyanosis, tachcardia. 4. Increased temperature, increase in respirations.

2. Widening pulse pressure, slowed respirations, bradycardia.

The nurse provides care for an adolescent client after a skateboard accident that resulted in a brief episode of unconsicousness. The client's scalp and facial lacerations were treated and dressed in the emergency department. which nursing care measure is the HIGHEST priority? 1. change the head wound dressings. 2. perform neurological checks frequently. 3. administer antiemetic medications. 4. Manage the client's report of a headache.

2. perform neurological checks frequently.

While providing care for a client dx with an intraranial bleed, the nurse notes the pupils are unequal at 2mm and 5mm, the larger pupil is non-reactive to light, and the client only responds to pain. Which explanation does the nurse determine based on this assessment? 1. the client is blind in one eye. 2. the client has symptoms of IICP 3. These are expected effects from narcotions the client received 4. these findings are abnormal but not significant

2. the client has symptoms of IICP

The nurse provides care for a client with expressive aphasia due to dysarthria from a stroke. Which techniqu is most appropriate for the nurse to use when helping the client communicate? 1. Speaking slowly and with a raised volume 2.Encouraging the client to use gestures 3. Allowing the client to speak in short phrases. 4. reminding the client to swallow before speaking

3. Allowing the client to speak in short phrases.

The nurse provides care for a client dx with IICP. Which is the most important short-term goal? 1. Encourage coughing & deep breathing 2. maintain client in supine position with limited movement 3. Control agitation and restlessness 4. avoid bright lights

3. Control agitation and restlessness

The nurse assess a client diagnosed with cerebral contusion and IICP. Which is the correct initial nursing aciton? 1. Placing a footboard to decrease foot drop. 2. Encouraging head movement to the right. 3. Elevating HOB 15-30 degrees 4. Suctioning q2h to maintain the airway

3. Elevating HOB 15-30 degrees

The nurse provides care for a child diagnosed with a serious closed head injury. The client's parent says to the nurse, "Will my child be all right? Is my child going to die? I'm so scared" Which response by the nurse is the best? 1. "of course your child will be all right. It will take time for your child to get better." 2. "I'll be avaiable if you have any questions. Here is a booklet on head injuries" 3. It must be frightening to see your child hurt. 4. "Its too soon to know the outcome. Would you like to talk with the HCP?

3. It must be frightening to see your child hurt.

A client dx with IICP is drowsy, but will follow commands, and pupils are equal and briskly reactive. When the nurse performs an assessment 2 hours later, the client is more difficult to rouse and pupikls are dilated and sluggishly reactive. How does the nurse interpret this data? 1. The client needs to have uninterrupted rest. 2. The client is experinecing improved cerebral function. 3. The clien'ts condition is deteriorating. 4. The client has experienced a morphine sulfate OD

3. The clien'ts condition is deteriorating.

The nurse notes a client is able to open the eyes spontaneously, follow command to hold up two fingers, and correclty identify the day of the week and current location. Using the GCS, which score does the nurse correctly assign to the client? 1. 3 2. 6 3. 10 4. 15

4. 15

Which assessment does the nurse make first when providing care for a client dx with a closed head injury? 1. Level of cognitive funciton 2. Fluid and Electrolyte balance 3. LOC 4. Airway and Respiratory Status

4. Airway and Respiratory Status

A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? a. Increased pressure from the abscess can cause seizures. b. Preventing febrile seizures with an abscess is important. c. Seizures always occur in clients with brain abscesses. d. This drug is used to sedate the client with an abscess.

ANS: A Brain abscesses can lead to seizures as a complication. The nurse should explain this to the spouse. Phenytoin is not used to prevent febrile seizures. Seizures are possible but do not always occur in clients with brain abscesses. This drug is not used for sedation.

A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? a. Call the provider or Rapid Response Team. b. Increase the rate of the IV fluid administration. c. Notify respiratory therapy for a breathing treatment. d. Prepare to give IV pain medication.

ANS: A These manifestations indicate Cushings syndrome, a potentially life-threatening increase in intracranial pressure (ICP), which is an emergency. Immediate medical attention is necessary, so the nurse notifies the provider or the Rapid Response Team. Increasing fluids would increase the ICP. The client does not need a breathing treatment or pain medication

A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the clients care? (Select all that apply.) a. Assess tube placement per agency policy. b. Keep the head of the bed elevated at least 30 degrees. c. Listen to lung sounds at least every 4 hours. d. Run continuous feedings on a feeding pump. e. Use blue dye to determine proper placement.

ANS: A, B, C, D All of these options are important for client safety when continuous enteral feedings are in use. Blue dye is not used because it can cause lung injury if aspirated.

A nurse cares for older clients who have traumatic brain injury. What does the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age-group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age-group.

ANS: A, C, D Older adults often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor crashes

A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) a. Admission can overwhelm the coping mechanisms for older clients. b. Alcohol is typically involved in most traumatic brain injuries for this age group. c. These clients are more susceptible to systemic and wound infections. d. Other medical conditions can complicate treatment for these clients. e. Very few traumatic brain injuries occur in this age group.

ANS: A, C, D Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and noisy. Because of decreased protective mechanisms, they are more susceptible to both local and systemic infections. Other medical conditions can complicate their treatment and recovery. Alcohol is typically not related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.

A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) a. A client with a moderate trauma may need hospitalization. b. A Glasgow Coma Scale score of 10 indicates a mild brain injury. c. Only open head injuries can cause a severe TBI. d. A client with a Glasgow Coma Scale score of 3 has severe TBI. e. The terms mild TBI and concussion have similar meanings.

ANS: A, D, E Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale (GCS) score of 9 to 12, and these clients may need to be hospitalized. Both open and closed head injuries can cause a severe TBI, which is characterized by a GCS score of 3 to 8.

16. A client with a traumatic brain injury is agitated and fighting the ventilator. What drug should the nurse prepare to administer? a. Carbamazepine (Tegretol) b. Dexmedetomidine (Precedex) c. Diazepam (Valium) d. Mannitol (Osmitrol)

ANS: B Dexmedetomidine is often used to manage agitation in the client with traumatic brain injury. Carbamazepine is an antiseizure drug. Diazepam is a benzodiazepine. Mannitol is an osmotic diuretic.

After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? a. Assess the clients magnesium level. b. Assess the clients sodium level. c. Increase the rate of the IV infusion. d. Provide oral care every hour.

ANS: B This client has manifestations of hypernatremia, which is a possible complication after craniotomy. The nurse should assess the clients serum sodium level. Magnesium level is not related. The nurse does not independently increase the rate of the IV infusion. Providing oral care is also a good option but does not take priority over assessing laboratory results.

A nurse is caring for four clients who might be brain dead. Which client would best meet the criteria to allow assessment of brain death? a. Client with a core temperature of 95 F (35 C) for 2 days b. Client in a coma for 2 weeks from a motor vehicle crash c. Client who is found unresponsive in a remote area of a field by a hunter d. Client with a systolic blood pressure of 92 mm Hg since admission

ANS: B In order to determine brain death, clients must meet four criteria: 1) coma from a known cause, 2) normal or near-normal core temperature, 3) normal systolic blood pressure, and 4) at least one neurologic examination. The client who was in the car crash meets two of these criteria. The clients with the lower temperature and lower blood pressure have only one of these criteria. There is no data to support assessment of brain death in the client found by the hunter.

A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self-management? (Select all that apply.) a. Does not want to purchase a thermometer b. Is allergic to acetaminophen (Tylenol) c. Laughing, says Strenuous? Whats that? d. Lives alone and is new in town with no friends e. Plans to have a beer and go to bed once home

ANS: B, D, E Clients should take acetaminophen for headache. An allergy to this drug may mean the client takes aspirin or ibuprofen (Motrin), which should be avoided. The client needs neurologic checks every 1 to 2 hours, and this client does not seem to have anyone available who can do that. Alcohol needs to be avoided for at least 24 hours. A thermometer is not needed. The client laughing at strenuous activity probably does not engage in any kind of strenuous activity, but the nurse should confirm this.

27. The nurse assesses a clients Glasgow Coma Scale (GCS) score and determines it to be 12 (a 4 in each category). What care should the nurse anticipate for this client? a. Can ambulate independently b. May have trouble swallowing c. Needs frequent re-orientation d. Will need near-total care

ANS: C This client will most likely be confused and need frequent re-orientation. The client may not be able to ambulate at all but should do so independently, not because of mental status. Swallowing is not assessed with the GCS. The client will not need near-total care.