Exam #3: Head Injury Quiz

A patient is admitted with suspected acute subdural hematoma on the right side of the brain. The nurse will assess for 1) Headache, drowsiness, right-sided hemiparesis, and contralateral pupil dilation. 2) Headache, ipsilateral pupil dilation and cyanosis. 3) Drowsiness, headache, confusion, and ipsilateral pupil dilation. 4) Drowsiness, confusion, hemiparesis, and contralateral pupil dilation

3

Quick, jerky, grossly uncoordinated, irregular movements that may disappear on relaxation are called which of the following? 1) Twitching 2) Spasticity 3) Choreiform movements 4) Associated movements

3

Which is true regarding Battle's sign? 1) Abnormal posturing in which all four extremities are in rigid extension. 2) Bleeding that occurs between the dura mater and the arachnoid meninges. 3) Characteristic of a basilar skull fracture 4) A lucid period followed by unconsciousness

3

An adult patient with a head injury is very agitated and uncooperative. He has intravenous lines and must have repeated neurologic checks. The nurse's best intervention to prevent injury is 1) Request an order for opioids from the doctor. 2) Provide the patient with repeated instructions to relax. 3) Instruct the family about the rationale for staying calm. 4) Wrap the patient's hands in thick mitts.

4

Part of the plan for a client with increased intracranial pressure is to maintain an adequate airway and promote gas exchange. To accomplish these goals, an effective nursing action is to 1) Encourage the client to cough vigorously. 2) Avoid hypercapnia in the client 3) Suction the client nasotracheally at frequent intervals. 4) Pack gauze in the nares when there is drainage from the nose.

2

The nurse is caring for a client with suspected acute subdural hematoma. Which sign should the nurse be most concerned about? 1) Increased blood pressure. 2) Decreased LOC. 3) Increased strength in arms. 4) Nausea

2

The nurse is caring for a patient with a head injury and notices that the patient's urine output has decreased over the last few hours. Also the specific gravity is increasing and serum osmolality is decreasing. What should the nurse do next? 1) Report a possible problem with antidiuretic hormone secretion. 2) Lower the head of the bed and check the output again in 4 hours. 3) Take the temperature and request an order to increase IV fluids. 4) Chart intake and output carefully for the next 24 hours.

1 A complication of head injury is problem with secretion of ADH from the posterior pituitary. The patient is at risk for developing SIADH or diabetes insipidus and the urine specific gravity is the most helpful in determining these problems. The signs in this case point toward diabetes insipidus. The MD will have to be notified and reporting urine urine output and sp. gr. values would be helpful and necessary before medications or IV changes are ordered. Temperature changes are not usually observed with ADH disorders. Waiting 24 hours to act on this would be waiting too long and the patient could develop serious fluid and electrolye problems.

The nurse is using the Glasgow Coma Scale (GCS) to assess a patient and knows that this scale measures which of the following? 1) Identification of person, place, time. 2) Pupillary response. 3) Deep tendon reflex activity. 4) Best respiratory efforts

1 The GCS assesses the patient's best verbal response when questioned. If the patient can identify self, place, and year and month, the patient is given 5 points. Fewer points are given if the patient is confused or cannot speak. Eye opening (not pupillary response) and best motor response are the other 2 parameters that are rated. Deep tendon reflex activity and assessment of respiratory effort are important aspects to assess but are not part of the GCS.

A nurse is caring for a client admitted to the hospital after sustaining a head injury. The nurse most appropriately positions the client: 1) with the head of the bed elevated 30-45 degrees 2) with the head elevated on pillow 3) in reverse Trendelenburg position 4) in left Sims' position

1 The HOB should be elevated with the neck straight to promote venous and CSF drainage which will decrease ICP. Anything that causes bending of the neck or kinking of neck vessels - such as providing a pillow - can cause an increase in blood or fluid in the head and this will increase ICP - something that we want to avoid. Reverse Trendelenberg would be too high and has legs dependent which could cause pooling of blood in the lower extremities. Left Sim's would not help increased ICP because the head remains flat.

The nurse is assigned to care for a patient who has increased intracranial pressure. Vital signs for the 11-7 shift were as follows: BP, 120/80, Pulse, 100, Resp. 22. During the 7:00 a.m. assessment, vital signs were as follows: BP 132/76, Pulse 90, Resp. 20. Thirty minutes later the vital signs are 140/72, Pulse 60, Resp. 12. Based on this data, what should be done first? 1) Notify the doctor immediately about these vital signs. 2) Draw blood gases to determine acid/base balance. 3) Lower the head of the bed to increase cerebral perfusion. 4) Increase the dosage of mannitol (Osmitrol) and administer dexamethasone (Decadron).

1 These vital signs indicate that intracranial pressure may be rising. (Cushing's triad) They should be reported immediately.

A client recovering from a head injury becomes agitated at times. Which action will most likely calm this client? 1) Turn on the television to a quiet musical program. 2) Offer the client a favorite object to hold, such as a stuffed animal. 3) Assign the client a new task to master. 4) Make the client aware that the behavior is undesirable.

2

Based on nursing knowledge, the nurse is aware that an epidural hematoma is classically characterized by 1) A long period of unconsciousness followed by complete lucidity. 2) A short period of unconsciousness followed by a lucid period, followed by rapid deterioration. 3) Slowly developing signs of increasing intracranial pressure. 4) No complaints of headaches, but other neurological signs.

2

Mannitol (Osmitrol) is administered intravenously to a client admitted to the hospital with loss of consciousness and a closed head injury. The nurse would evaluate the medication was most effective if which of the following outcomes was noted? 1) Diuresis of 500 mL in 2 hours and a blood urea nitrogen (BUN) level of 15 mg/dL 2) Improved level of consciousness and normal intracranial pressure 3) Weight loss of 1 kg and a serum creatinine level of 0.8 mg/dL 4) Serum creatinine level of 1.2 mg/dL and normal intracranial pressure

2 This is an evaluation question and outcomes must be considered. Because mannitol is given to draw off fluid from from the brain, improve brain cell functioning and prevent brain damage, improved LOC and normal ICP are the main indicators that the drug is doing its job. Even though this is an osmotic diuretic and we would expect an increase in urine output and weight loss from loss of fluid, these outcomes do not indicate effectiveness of this particular drug. Kidney function values do not give an indication of the effectiveness of this drug.

Which of the following are most commonly observed in patients with brainstem contusions? Choose all that apply. 1) Period of consciousness immediately after injury. 2) Symmetrical deficits in motor control. 3) Ipsilateral pupillary changes. 4) Bilateral pupillary changes

2 and 4

Increased intracranial pressure can be caused by which of the following? Choose all that apply. 1) Stimulation of the reticular activating system. 2) Drug overdose. 3) Diabetic ketoacidosis. 4) Kidney failure. 5) Cerebrovascular accident. 6) Smoking. 7) Ingestion of alcohol

2, 3, 4, and 5

An adult client has undergone a lumbar puncture to obtain cerebrospinal fluid (CSF) for analysis. A nurse assesses for which of the following values that should be negative if the CSF is normal? 1) Protein 2) Glucose 3) White blood cells 4) Red blood cells

4 In a normal specimen of CSF there is some glucose and protein because these substances flow freely from the blood to the CSF. The fluid resembles ultrafiltrate of the blood. Occasionally there normally will be a few WBC's. But if there are RBC's, this is an abnormality either due to a traumatic spinal tap or a disease process.

A nurse is monitoring the intracranial pressure (ICP) of a client with a head injury. The ICP is averaging 25 mm Hg. The nurse analyzes these results as: 1) Normal 2) Compensation, indicating adequate brain adaptation. 3) Borderline in elevation, indicating the initial stage of compensation. 4) Increased, indicating a serious compromise in cerebral perfusion.

4 Normal ICP is 0-15mm Hg. Increasing ICP causes decreased cerebral perfusion and eventually brain cell death. An initial stage of compensation would probably be 15-20 mm Hg. in which bloodflow diminishes and brain tissue contracts to help bring down pressure. When these mechanisms fail, there can be cerebral damage.

An patient with a head injury as a blood pressure of 120/60, and an intracranial pressure of 15. The nurse calculates the cerebral perfusion pressure as ____________.

MAP = [SBP + 2(DBP)]/3 = [120 + 2(60)]/3 = 240/3=80 CPP = MAP - ICP = 80 - 15= 65

A patient is admitted to the emergency room following an automobile accident. The paramedics report that he was initially unconscious at the scene of the accident, but awakened while he was being transported to the emergency room. He is alert to time, place, and person. His only complaint initially is a headache. Thirty minutes later, he is complaining of a severe headache, he is difficult to arouse,and he is no longer alert to time or place. X-ray shows a skull fracture in the right temporal area. These signs and symptoms are most characteristic of what type of head injury?

epidural hematoma