Pearson M.11-3: Dynamic Study Module Traumatic Brain Injury

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.

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? Administering anticonvulsant medications Administering oxygen via nasal cannula Preparing for imminent miscarriage Placing a fetal monitor on the patient

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.

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

Absence of spontaneous respirations

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

Arterial blood gas results

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? Glasgow Coma Scale score Arterial blood gas results Cranial nerve function Motor and sensory function

Refrain from sliding into the base headfirst.

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)? Refrain from sliding into the base headfirst. Wear your helmet when you are a pitcher. Notify the coach if you are feeling overtired. Refrain from tackling other players on the field.

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)? Asking someone to watch the baby when overwhelmed Removing toys and clutter from the floor and hallways Using seat belts and car safety seats when in a motor vehicle Taking the infant to a healthcare facility for treatment

Asking someone to watch the baby when overwhelmed

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? Suggesting a reduction in activity Preventing participation in contact sports Conducting a home safety assessment Restricting movement with chemical restraints

Conducting a home safety assessment

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?

Home modifications

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? Mental status Appetite Fluid volume Hearing

Mental status

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

Polypharmacy

Which nursing diagnosis would be most appropriate for a patient who needs assistance with personal care?

Self-care Deficit, Bathing

"A CT scan will determine the presence and location of any fractures of the skull or bleeding in the brain."

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 CT scan is used to determine the presence of tumors or abnormal growths that caused the problem." "A CT scan will help determine the presence of hearing or language difficulties related to the injury." "A CT scan is a diagnostic test that the healthcare provider will prescribe for all patients." "A CT scan will determine the presence and location of any fractures of the skull or bleeding in the brain."

The brainstem

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? The brainstem The thalamus The cerebellum The occipital lobe

Spending time with the patient in their room each day

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? Spending time with the patient in their room each day Assigning a roommate to the patient's room Arranging for the patient to attend a group activity Giving the patient books to read on their own

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 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? Slurred speech Repetitive hiccupping Diarrhea Constipation

Facing the patient and speaking clearly

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? Facing the patient and speaking clearly Limiting available choices for decision making Providing frequent orientation to time and place Promoting independence with daily self-care

Clear fluid from the patient's nose

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? Reports of muscular pain in the arms Clear fluid from the patient's nose Bruising to the lower extremities Alert and oriented to place and situation

Taking a shower with assistance in washing their back

The nurse is developing a plan of care for a patient who sustained a traumatic brain injury (TBI). The nurse develops a goal of performing morning care with minimal assistance. Which intervention should the nurse implement to facilitate the patient meeting this goal? The patient being independent only with oral and facial care The patient requiring help with getting dressed and bathing Taking a shower with assistance in washing their back The nurse performing 75% of the bath and morning care

Providing a dry erase board and a marker

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? Providing information about hearing aids Orienting the patient to person, place, and time Administering medications as prescribed Providing a dry erase board and a marker

Refraining from sports for at least 7-10 days

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

Wearing a helmet when skateboarding

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? Decreasing the amount of alcohol ingested Keeping pathways clear and free of cords Wearing a helmet when skateboarding Refraining from participating in all sports

Social worker

The nurse is working with a patient who sustained a traumatic brain injury (TBI) from a motor vehicle crash and will be discharged in a wheelchair. The patient reports three or four stairs to enter the house. Which member of the healthcare team would the nurse consult to help the patient find assistance for home modifications? Social worker Occupational therapist Physical therapist Psychologist

A rehabilitation center

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? Home health service An outpatient center A rehabilitation center A nursing home

Chaplain

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? Chaplain Psychiatrist Psychologist Surgeon

Antiseizure

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

Remove throw rugs and cords from pathways.

Which information should the nurse provide the family of an 85-year-old patient to prevent traumatic brain injuries (TBIs)? Remove throw rugs and cords from pathways. Avoid inadequate administration of medication. Prevent improper use of home safety equipment. Ensure use of seat belts when in vehicles.

A patient taking anticoagulant medication for atrial fibrillation

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

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

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? Swimming Jogging Bicycling Hockey

hockey