Traumatic Brain Injury

Which description best describes hydrocephalus?

An abnormal increase in cerebrospinal fluid in the brain. Rationale Hydrocephalus is an abnormal increase in cerebrospinal fluid. If left untreated, this condition can lead to increased intracranial pressure. A collection of blood is a blood clot. The shifting and herniating of brain tissue downward describes brain herniation. The fluid accumulation between the cells of the brain describes interstitial edema.

Which phrase describes an open TBI?

An injury in which the skull is fractured.

Which information does the nurse include when teaching a group of nursing students about neurologic assessment findings in patients with TBI? (select all that apply)

Ataxia may indicate damage to the cerebellum. Changes in the level of consciousness may indicate damage to teh cerebral cortex. An abnormal posture may indicate dysfunction in the motor tracts of teh spinal cord. Rationale Ataxia may indicate damage to the cerebellum or the brain stem. Damage to the cerebral cortex is suspected when the level of consciousness varies. An abnormal posture may indicate dysfunction in the motor tracts of the spinal cord. Hydrocephalus is an abnormal increase in the cerebrospinal fluid. Extraocular movements, not diplopia, are a clinical manifestation associated with hydrocephalus. Diplopia indicates damage to the optic chiasm. Changes in motor function indicate damage to the spinal cord, not the optic chiasm.

The nurse recognizes that which type of brain injury has occurred when the integrity of a patient's skill is intact but there is damage to the brain tissue as a result of increased intracranial pressure?

Closed traumatic brain injury. Rationale In a closed traumatic brain injury, the integrity of the skull is intact, but damage to the brain tissue still occurs as a result of increased intracranial pressure. An acceleration injury is caused by an external force contacting the head, suddenly placing the head in motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. An open traumatic brain injury occurs when the skull is fractured or pierced by a penetrating object.

Which phrase describes traumatic brain injury (TBI)?

Damage to the brain from an external mechanical force. Rationale TBI is damage to the brain from an external mechanical force. It is not caused by congenital conditions, neurodegeneration, or internal forces.

The nurse corrects which intervention when it is performed on a patient with moderate TBI?

Elevating the head of the bed to 15 degrees. It should be 30-45 degrees to prevent aspiration. Rationale The head of the bed should be elevated at 30 to 45 degrees for patients with MTBI to prevent aspiration. The nurse intervenes to correct the elevation of the bed to keep the patient safe. The head and neck should be maintained in the midline, neutral position. Log rolling the patient during turning is the correct way to reposition a patient so as to avoid extreme hip flexion. With patients who have MTBI, it is important to monitor peripheral oxygen saturation continuously.

Which statement describes an indirect TBI?

Force was applied to another body part, but the brain was still affected.

Which statement about subdural hematoma is accurate?

SDHs often are unrecognized until patients present with severe neurologic compromise. Rationale SDHs have the highest mortality rate because they often are unrecognized until patients present with severe neurologic compromise. An SDH results from venous bleeding, not arterial bleeding. Acute subdural hematoma presents within 48 hours after impact. An SDH results from venous bleeding into the space beneath the dura and above the arachnoid

The nurse expects which physiologic even when a patient's laboratory report shows an intracranial pressure of 12 mm Hg?

The body will function normally. Normal range is 10-15 mm Hg.

Which type of traumatic brain injury is caused by an external force contacting the head, suddenly placing the head in motion?

acceleration injury

Which type of injury is caused by an external force contacting the head, placing the head in sudden motion?

acceleration injury Rationale An acceleration injury is one in which an external force contacts the head and places the head in sudden motion. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. A focal injury is confined to a specific area of the brain. A diffuse injury is when many areas of the brain are damaged.

Which symptom concerns the nurse the most when assessing a patient with a TBI after a skateboarding accident?

asymmetric pupils Rationale Asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral dilated pupils are a sign of a severe TBI. Pupil changes are treated as herniation of the brain from increased intracranial pressure (ICP) until proven differently. The nurse should report and document any changes in pupil size, shape, and reactivity to the health care provider immediately because they could indicate an increase in ICP. Amnesia, a head laceration, and restlessness can be symptoms of mild TBI.

Which term is used to describe loss of balance in a patient with a brainstem or cerebellar injury?

ataxia

Which assessment parameter is a priority in the management of a patient with a brain injury?

level of consciousness Rationale The most important variable to assess in any brain injury is LOC. The first sign of deterioration in neurologic status is a decrease or change in LOC. Secondary assessments include ICP measurements, a CBC, and determination of the presence of a CSF leak.

When caring for a patient with increased ICP, the nurse anticipates a prescription for which drug that pulls water out of the extracellular space of the edematous brain tissue?

mannitol

How does the nurse respond when a patient with a mild traumatic brain injury asks, "I was injured 24 hours ago. How much longer will my symptoms last?"

"Some or most of your symptoms will likely resolve with 48 more hours." Rationale The nurse is correct to inform the patient that the symptoms will likely resolve within 48 more hours because symptoms usually resolve within 72 hours and the patient has already had the symptoms for 24 hours as the injury occurred 1 day ago. It is inappropriate to tell the patient that he or she should already be feeling better because it has only been 1 day since the onset of the MTBI and symptoms usually resolve in 72, not 24, hours. It is incorrect to tell a patient with an MTBI that sometimes the symptoms will never go away because symptoms, even if they persist and last for days, weeks, or months, can go away eventually. Some symptoms can persist for a couple of months after an MTBI, and this is referred to as postconcussion syndrome. However, this is not the best response as symptoms usually resolve within 72 hours.

Within which time frame do the symptoms of mild traumatic brain injury (MTBI) usually resolve?

72 hours Rationale Symptoms of an MTBI include a wide array of physical and cognitive problems that range from headache and dizziness to behavioral changes. These symptoms usually resolve within 72 hours. Symptoms of MTBI do not typically resolve within 30 minutes, 6 hours, or 24 hours.

Which type of skull fracture does the nurse suspect when there is leakage of fluid from a patient's nose and ears?

A basilar skull fracture - occurs at the base of the skull and usually extends into the anterior, middle, or posterior fossa regions of the brain, resulting in the leakage of CSF form the nose or ears. Rationale The nurse should carefully observe the patient's ears and nose for any signs of cerebrospinal fluid (CSF) leaks that result from a basilar skull fracture. A basilar skull fracture occurs at the base of the skull and usually extends into the anterior, middle, or posterior fossa regions of the brain, resulting in leakage of CSF from the nose or ears. The hemorrhage occurs because of damage to the internal carotid artery. A linear fracture is a simple, clean break in which the impacted area of bone bends inward and the area surrounding it bends outward. In a depressed fracture, the bone is pressed inward into the brain tissue to at least the thickness of the skull. A comminuted fracture is characterized by the presence of fragmented bone with depression into the brain tissue.

The nurse identifies which major overall desired outcome for rehabilitation for a patient after a brain injury?

Achieving the highest level of functioning. Rationale The major overall desired outcome for rehabilitation after brain injury is to maximize the patient's ability to return to his or her highest level of functioning. Prevention of injury from falls, infection, or further impairment of cerebral perfusion is part of a larger goal for this patient. The nurse assesses cerebral perfusion, such as oxygenation status, but cannot increase cerebral perfusion. Prevention of respiratory distress is also part of a larger goal for this patient.

The nurse anticipates that which initial diagnostic test will be performed to identify the scope and extent of damage in a patient after a traumatic brain injury?

CT

Which finding suggests that drainage from a patient's ear is cerebrospinal fluid?

It is positive for glucose. Rationale Although not a 100% accurate evaluation, CSF does test positive for glucose. When placed on a white absorbent background, CSF can be distinguished from other fluids by the "halo" sign, a yellowish stain surrounded by bloody drainage. CSF drainage does not dry to crystals and should not have purulent odor.

Which variable is the most important to assess with any brain injury?

Level of consciousness. Rationale LOC is the most important variable to assess with any brain injury. The first sign of increased intracranial pressure is a declining LOC. Heart rate, blood pressure, and body temperature can be assessed after LOC is evaluated.

The nurse expects which assessment finding when a patient with traumatic brain injury experiences ataxia?

Loss of balance. Rationale Ataxia means loss of balance. Ataxia does not mean that the patient has hypotension, a blood clot, or an inability to distinguish colors.

Which diagnostic test is performed to detect subtle changes in brain tissue and show more specific details of a brain injury?

MRI

Since admission to the hospital after a TBI, a patient has been active and oriented and experiencing mild headaches. Which action does the nurse take when increased dilation of the pupils and a sluggish response to light are new assessment findings?

Notify the health care provider immediately. Rationale Changes in pupil size or reactivity can indicate increased intracranial pressure, even several days after the trauma event. The nurse should notify the health care provider immediately. Performing more assessments only delays immediate action.

Which nursing action is priority when a patient who presents to the ED with an indirect injury to the head has an ICP of 18 mm Hg?

Notify the health care provider. Rationale A normal level of ICP is 10 to 15 mm Hg. The priority action for a patient with an increased ICP of 18 mm Hg is to notify the health care provider because increased ICP is the leading cause of death from head trauma in patients who reach the hospital alive. Applying an ice pack, administering an anti-inflammatory, and sitting the patient up are not priority actions at this time.

Which phrase describes a secondary brain injury?

Occurs after the initial injury.

Which inference does the nurse make when diagnostic tests of a patient with TBI reveal that the brain is contused?

The patient's brain is bruised. Rationale Contused is another word for bruised. If the patient had a shearing injury, the health record would indicate nerve axonal injury. If the patient's brain were torn, the health record would indicate a laceration. A direct injury does not describe a contusion.

Which information does the nurse include when discussing open traumatic brain injury with a group of nursing students? (select all that apply)

The skull is fractured or is pierced by a penetrating object. It is primary brain damage that results from the physical stress within the tissue. Damage may occur to the underlying vessels, dural sinuses, brain, and cranial nerves. There is exposure to environmental contaminants. The integrity of the dura is violated.

The nurse questions which item that is listed on the assessment checklist for a patient who presents with a TBI?

Wait until the patient gains consciousness to ask questions about the injury. Rationale If the patient is unconscious or cannot provide the information, the history of injury should be taken from first responders or witnesses. It is important to obtain the patient's history of alcohol use because it may cause alterations during neurologic assessments. The patient's level of consciousness should be checked to learn if any neurologic problem has occurred because of the brain injury. It is essential to ask the patient when, where, and how the injury occurred because it will help in further diagnosis and effective treatment of the injury.

How does deceleration injury occur?

When the moving head is suddenly stopped or hits a stationary object. Rationale A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. Closed traumatic brain injuries are caused by blunt force. Usually brain injuries occur when a mechanical force is applied either directly or indirectly to the brain. An open traumatic brain injury occurs when the skull is fractured or when it is pierced by a penetrating object. An acceleration injury is caused by an external force contacting the head that suddenly places the head in motion.

During which time frame does an acute subdural hematoma present after impact?

Within 48 hours. Rationale Acute SDHs present within 48 hours after impact. A subacute SDH will present within 48 hours to 2 weeks after impact. A chronic SDH will present from 2 weeks to several months after impact.

The nurse identifies that the patient is experiencing which complication associated with a brain injury when the assessment findings include tachypnea followed by periods of apnea, nonreactive pupils, and an abnormal protrusion of the brainstem into other brain tissue?

central herniation Rationale Central herniation is caused by a downward shift of the brainstem and the diencephalon from a supratentorial lesion. The manifestations include Cheyne-Stokes respirations, characterized by an abnormal pattern of breathing, and nonreactive pupils. Hydrocephalus is an abnormal increase in cerebrospinal fluid volume caused by impaired fluid reabsorption or blockade of fluid outflow from the ventricular system. Uncal herniation is caused by a shift of the temporal lobe in the brain tissue. It is manifested by dilated and nonreactive pupils, ptosis, and a rapidly deteriorating level of consciousness. An intracerebral hemorrhage is an accumulation of blood within the brain tissue associated with tearing of small arteries and veins in the subcortical white matter.

The nurse anticipates that which test will be prescribed to confirm brain death in a patient?

cerebral angiography Rationale Neuroimaging tests are not required to confirm brain death, but they are desirable. These tests include cerebral angiography, bedside electroencephalography (EEG), and cerebral CT angiography (CTA). Radiography and CT scanning of the cervical spine and the skull are done to rule out fractures and dislocations. The integrity of the cerebral vessels is measured through the use of ultrasonography. An ECG is not used to confirm brain death.

Which injury occurs when the moving head is suddenly stopped or hits a stationary object?

deceleration injury

Which type of primary brain injury will be initially at a microscopic level and not detectable by a CT scan?

diffuse injury Rationale Diffuse injuries are characterized by damage throughout many areas of the brain. They initially may be at a microscopic level and are not initially detectable by a CT scan. A focal brain injury is confined to a specific area of the brain and causes localized damage that can often be detected with CT or MRI. A force produced by a blow to the head is a direct injury. A force applied to another body part with a rebound effect to the brain is an indirect injury.

Which sleep disturbance is associated with mild TBI? (select all that apply)

drowsiness sleeping for long hours Rationale Drowsiness and sleeping for long hours may contribute to sleep disturbances in a patient with mild traumatic brain injury. Amnesia is a cognitive finding and is not related to sleep disturbance. Irritability and nervousness are emotional changes that occur after a brain injury.

The nurse discusses which common cause of TBI in older adults when providing education for a community group?

falls

Which causes of traumatic brain injury in the US are the most common? (select all that apply)

falls motor vehicle crashes Rationale The most common causes of TBI in the United States are falls and motor vehicle crashes. Sports-related injuries, violence, and physical abuse are not the most common causes of TBI.

Which type of brain injury is confined to a specific area of the brain?

focal injury Rationale A focal brain injury is confined to a specific area of the brain and causes localized damage that can often be detected with CT or MRI. A force produced by a blow to the head is a direct injury. Diffuse injuries are characterized by damage throughout many areas of the brain. A force applied to another body part with a rebound effect to the brain is an indirect injury.

Which drug is often used as adjunctive therapy to reduce the incidence of rebound from mannitol?

furosemide

Which tool is used to measure the severity of a traumatic brain injury?

glasgow coma scale

When placing CSF on a white absorbent paper, which distinguishing feature helps the nurse differentiate CSF from other types of fluid?

halo sign Rationale CSF when placed on a white absorbent paper or linen can be distinguished from other fluids by the "halo" sign. The halo sign is a clear or yellowish ring surrounding a spot of blood. The battle sign, or mastoid ecchymosis, is bruising behind the ears and lower jaw. A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. CSF is not milky in appearance.

Which assessment finding is associated with postconcussion syndrome? (select all that apply)

headaches dizziness impaired cognition

Which condition damages a patient's brain tissue and contributes to cerebral vasodilation and increased ICP?

hypoxemia - abnormally low concentration of oxygen in the blood which can damage the brain tissue and contribute to cerebral vasodilation and increased ICP.

Which is the leading cause of death from head trauma in patients who reach the hospital alive?

increased intracranial pressure Rationale Increased ICP is the leading cause of death in patients who reach the hospital alive after having head trauma. Internal bleeding is a risk factor for death, but it is not the leading cause. Hypoxia and hypotension commonly cause secondary injuries but are not the leading cause of death.

The nurse suspects which diagnosis when a patient's assessment findings include a recent blow to the head with a heavy object, amnesia about the event, no LOC, and an MRI that shows no evidence of brain damage?

mild traumatic brain injury Rationale The nurse understands that this patient has characteristics of an MTBI. With MTBIs, CT and MRI scans do not show evidence of any brain damage, and patients may report memory loss for events immediately before or after the accident. With moderate TBI, patients have loss of consciousness, and CT and MRI scans usually show brain injury. There is no such category as acute TBI. With severe TBI, the patient has loss of consciousness, and CT and MRI scans catch tissue damage in the brain early.

An impairment of which function can be the result of traumatic brain injury? (select all that apply)

mobility cognition sensory perception psychosocial function

Which level of brain injury is present in a patient with a glasgow coma scale score ranging from 9-12?

moderate traumatic brain injury

After assessing an intubated patient with hypocarbia, the nurse determines that which finding should be reported to the health care provider immediately?

nonreactive, dilated pupils Rationale Hypocarbia is caused by hyperventilation and can lead to profound vasoconstriction with resulting ischemia. The early detection of changes in the patient's neurologic status enables the health care team to prevent or treat potentially life-threatening complications. The nurse should be aware that subtle changes in blood pressure, consciousness, and pupillary reaction to light can be very informative about neurologic deterioration. The patient's body temperature is slightly low, but this is not alarming or an emergency. The patient's heart rate is close to normal for an adult. The patient's arterial pH level is also close to normal range (7.35 to 7.45) and would be consistent with low arterial carbon dioxide or hypocarbia, so it is not urgent.

Which word is used to classify a primary brain injury? (select all that apply)

open or closed Rationale Primary brain injuries are classified as open or closed. Diffuse injuries are when there is damage done to many areas of the brain. Focal injuries are when damage is only concentrated in one specific area of the brain. Accelerated injuries are when the head is moved suddenly by a force. Decelerated injuries are when the head is moving and is suddenly stopped.

Which injury is characterized by a fractured skull?

open traumatic brain injury Rationale An open traumatic brain injury occurs when the skull is fractured or when it is pierced by a penetrating object. Diffuse injuries are characterized by damage throughout many areas of the brain. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. Closed traumatic brain injuries are caused by blunt force. The blunt force can either be direct or caused by a blast shockwave.

Which injury occurs when the skull is fractured or when it is pierced by a penetrating object?

open traumatic brain injury Rationale An open traumatic brain injury occurs when the skull is fractured or when it is pierced by a penetrating object. Diffuse injuries are characterized by damage throughout many areas of the brain. A deceleration injury occurs when the moving head is suddenly stopped or hits a stationary object. Closed traumatic brain injuries are caused by blunt force. The blunt force can either be direct or caused by a blast shockwave.

Which drug is given to a patient to prevent seizure activity that occurs with some types of specific brain injuries?

phenytoin Rationale Antiepileptic drugs, such as phenytoin, are not recommended routinely to prevent seizures. However, they may be administered to prevent early-onset seizure activity that may occur with some types of specific brain injuries. Propofol and dexmedetomidine are sedative agents used as continuous infusions to manage agitation and ventilatory asynchrony. Furosemide, a loop diuretic, is often given to patients as an adjunctive therapy to reduce the incidence of rebound from mannitol.

The nurse monitors for which indication of increased ICP in a patient with TBI from a motor vehicle crash?

projectile vomiting Rationale Nausea and vomiting, often projectile, are key features of ICP. Dizziness is indicative of brain injury. Cushing triad is a very late sign and includes severe hypertension, widened pulse pressure, and bradycardia.

Which type of assessment is the nurse performing when listening to family members discuss feelings of guilt and anger over a patient's traumatic brain injury?

psychosocial

Which type of hemorrhage results from venous bleeding into the space beneath the dura and above the arachnoid?

subdural hematoma Rationale A subdural hematoma results from venous bleeding into the space beneath the dura and above the arachnoid. An epidural hematoma results from arterial bleeding into the space between the dura and the inner skull. Traumatic intracerebral hemorrhage is the accumulation of blood within the brain tissue caused by the tearing of small arteries and veins in the subcortical white matter. A subarachnoid hemorrhage results from bleeding into the subarachnoid space. It is usually caused by a ruptured aneurysm, arteriovenous malformation, or trauma.

To treat a patient with a severe TBI, which intervention reduces brain metabolism and prevents the cascade of molecular and biochemical events that contribute to secondary brain injury?

therapeutic hypothermia Rationale The purpose of therapeutic hypothermia is to rapidly cool the patient to a core temperature of 89.6°F to 93.2°F (32°C to 34°C) for 24 to 48 hours after the primary injury. The rationale for therapeutic hypothermia is to reduce brain metabolism and prevent the cascade of molecular and biochemical events that contribute to secondary brain injury in moderate-to-severe TBI. A barbiturate coma is a temporary state of unconsciousness brought on by a controlled dose of a barbiturate drug. An intraventricular catheter is a monitoring device that allows accurate measurement of intracranial pressure (ICP). In extreme cases in which the patient's ICP cannot be controlled, the physician may elect to perform a decompressive craniectomy (removal of a section of the skull) to remove ischemic brain tissue or the tips of the temporal lobes.

Which assessment finding suggests that a patient's ICP is increasing? (select all that apply)

vomiting dilated pupils papilledema Rationale Signs of increasing ICP include papilledema, dilated pupils, and vomiting. The patient will experience hypercapnia, not hypocapnia. Glucose levels would not be affected. Signs of increasing ICP include an ICP level of greater than 15 mm Hg.

Which factor is implicated in the greatest number of injuries associated with TBI? (select all that apply)

weekends alcohol use evenings and nights Rationale The greatest contributing factors to TBIs are timing during evenings and nights, weekends, and alcohol or drug use. Timing during the spring and summer months, not winter months, are contributing factors. TBIs are not as likely to occur in the morning as they are in the evening and night.