Test 3- Traumatic Brain Injury Practice Questions

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? 1) The MRI will be repeated to determine the cause of the​ client's injuries. 2) It can take hours to days for contusions to form from a​ coup-contrecoup injury. 3) It is protocol for all MRIs to be repeated in traumatic brain injuries​ (TBIs). 4) The MRI can determine the grade of concussion that the client sustained.

2) It can take hours to days for contusions to form from a​ coup-contrecoup injury. Brain contusions are classified as coup or contrecoup. Individuals can also have a​ coup-contrecoup injury. It can take a few hours to a few days to determine the full extent of the injury from these contusions.​ Therefore, the MRI would be repeated in a few days to determine the full extent of the injury. The healthcare provider knows the cause of the injuries. It may be​ protocol, but that does not explain the reason MRIs are repeated.

A nurse assesses the patient's LOC using the Glasgow Coma Scale. What score indicates severe impairment of neurologic function?

3

The GCS score for your client with a risk for increased intracranial pressure has been stable at 12 for the last 6 hours. This time you rate him at 9. Which of the following have you noted and what does it mean? A. He is less responsive, a sign that his intracranial pressure may be increasing B. He is more responsive, a sign that he may be improving C. His pupils are fixed and dilated, an ominous sign D. He does not move or make sounds, which may mean he got too much pain medication

A. He is less responsive, a sign that his intracranial pressure may be increasing

A 17 year-old man is admitted to the Trauma Intensive Care Unit after sustaining a closed head injury in a gang related fight. The nurse in the Emergency Department (ED) reported that his VS before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS: BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate response to this assessment data? A. Inform the attending physician of the change in assessment B. Give the client intravenous naloxone (Narcan) as ordered C. Call the laboratory and request a stat blood draw for drug screen D. Lower the head of the client's bed flat immediately

A. Inform the attending physician of the change in assessment

A nurse is caring for a client with a brain tumor and increased intracranial pressure (ICP). Which intervention should the nurse include in the care plan to reduce ICP?

Administer stool softeners.

Which is a late sign of increased intracranial pressure (ICP)?

Altered respiratory patterns

The nurse administers intravenous mannitol for an unconscious client. A decrease in which of the following is expected as a therapeutic effect of this drug? A. Seizure activity B. Cerebral edema C. Cerebral metabolism D. Cerebral inflammation

B. Cerebral Edema

A client has fluid leaking from the nose after a basilar skull fracture. Which of the following would indicate that the fluid is cerebrospinal fluid? A. It clumps together on the paper and has a pH of 7 B. It leaves a yellowish ring on the paper and tests positive for glucose. C. It is grossly bloody in appearance and has a pH of 6. D. It is clear in appearance and tests negative for glucose.

B. It leaves a yellowish ring on the paper and tests positive for glucose.

Which signs are manifestations of the Cushing triad? Select all that apply.

Bradypnea, Bradycardia, Hypertension

An older client complains of a constant headache. A physical examination shows papilledema. What may the symptoms indicate in this client?

Brain tumor

Which of the following represents the best explanation of secondary brain injury? A. Trauma to the brain causes bleeding and swelling of the tissues increasing pressure within the brain B. Trauma to neurons from the impact of the injury impairs brain function C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling D. Swelling of the axon of the nerve causes it to disconnect from the cell body interrupting conduction of the impulse

C. Breathing problems and low blood pressure cause chemical changes that contribute to brain swelling

Nurse observes that the client has extension and external rotation of the arms and wrists and plantar flexion of the feet the nurse records the client's posture as

Decerebrate

A client experiences loss of consciousness, tongue biting, and incontinence, along with tonic and clonic phases of seizure activity. The nurse should document this episode as which type of seizure?

Generalized

Which term refers to the shifting of brain tissue from an area of high pressure to an area of low pressure?

Herniation

The nurse is caring for a patient with increased ICP. As the pressure rises, what osmotic diuretic does the nurse prepare to administer?

Mannitol dehydrates the brain & reduces cerebral edema

A client who was trapped inside a car for hours after a head-on collision is rushed to the emergency department with multiple injuries. During the neurologic examination, the client responds to painful stimuli with decerebrate posturing. This finding indicates damage to which part of the brain?

Midbrain

A nurse is continually monitoring a client with a traumatic brain injury for signs of increasing intracranial pressure. The cranial vault contains brain tissue, blood, and cerebrospinal fluid; an increase in any of the components causes a change in the volume of the others. This hypothesis is called which of the following?

Monro-Kellie

The nurse is caring for the client with increased intracranial pressure. The nurse would note which of the following trends in vital signs if the ICP is rising? a.) Increasing temperature, increasing pulse, increasing respirations, decreasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure. c.) Decreasing temperature, decreasing pulse, increasing respirations, decreasing blood pressure. d.) Decreasing temperature, increasing pulse, decreasing respirations, increasing blood pressure. b.) Increasing temperature, decreasing pulse, decreasing respirations, increasing blood pressure.

Rationale: A change in VS may be a LATE sign of increased intracranial pressure. Trends include increasing temperature and blood pressure and decreasing pulse and respiration. Respiratory irregularities also may arise.

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? Unequal pupils Raccoon eyes Irritability Tinnitus

Unequal pupils Unequal pupils indicate that the (TBI) was more severe than was actually diagnosed. This neuro deficit would require further​ follow-up from a neurologist to determine possible cranial nerve damage or damage to the ocular portion of the brain.​ Tinnitus, irritability, and raccoon eyes are all manifestations of a mild TBI & and should resolve with rest.

Which method is used to help reduce intracranial pressure?

Using a cervical collar b/c it prevents further damage

When evaluating an ABG from a client with a subdural hematoma, the nurse notes the PaCO2 is 30 mm Hg. Which of the following responses best describes this result? a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). b.) Emergent; the client is poorly oxygenated. c.) Normal d.) Significant; the client has alveolar hypoventilation.

a.) Appropriate; lowering carbon dioxide (CO2) reduces intracranial pressure (ICP). Rationale: A normal PaCO2 value is 35 to 45 mm Hg. CO2 has vasodilating properties; therefore, lowering PaCO2 through hyperventilation will lower ICP caused by dilated cerebral vessels. Oxygenation is evaluated through PaO2 and oxygen saturation. Alveolar hypoventilation would be reflected in an increased PaCO2.

A client with subdural hematoma was given mannitol to decrease intracranial pressure (ICP). Which of the following results would best show the mannitol was effective? a.) Urine output increases b.) Pupils are 8 mm and nonreactive c.) Systolic blood pressure remains at 150 mm Hg d.) BUN and creatinine levels return to normal

a.) Urine output increases Rationale: Mannitol promotes osmotic diuresis by increasing the pressure gradient in the renal tubes. Fixed and dilated pupils are symptoms of increased ICP or cranial nerve damage. No information is given about abnormal BUN and creatinine levels or that mannitol is being given for renal dysfunction or blood pressure maintenance.

A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after falling out of a tree house. The mechanisms of injury this young client most likely sustained would be: a.) Acceleration b.) Penetrating c.) Rotational d.) Deceleration

d.) Deceleration Rationale: occurs when the brain stops rapidly in the cranial vault. As the skull ceases movement, the brain continues to move until it hits the skull. The force of deceleration causes injury at the site of impact. An example of this is a victim of a fall.

PREP U A nurse is monitoring a client for increasing intracranial pressure (ICP). Early signs of increased ICP include

diminished responsiveness

A nurse is caring for a client in a coma who has suffered a closed head injury. What intervention should the nurse implement to prevent increases in intracranial pressure (ICP)?

elevate HOB 30 degrees

Nurse assessing a patient's urinary output as an indicator of diabetes insipidus. The nurse knows that an hourly output of what volume over 2 hours may be a positive indicator?

more than 200 mL/hr

The nurse is assessing the client with a traumatic brain injury after a skateboarding accident. Which symptom is the nurse most concerned about? A. Amnesia for events of accident B. Bleeding head laceration C. Pupil changes in one eye D. Restlessness and confusion

C. Pupil changes in one eye

Your client is a morbidly obese 63 year-old female who sustained a closed head injury when she slipped on a wet floor in the supermarket. She is in the Intensive Care Unit, on a ventilator, and has intracranial pressure monitoring. Which of the following interventions is least likely to be a part of her plan of care? A. Nasogastric tube feeding around the clock B. Turning every 2 hours with skin care C. Suction every one hour and as needed D. Sterile dressing change to ICP monitoring catheter

C. Suction every one hour and as needed

Which posture exhibited by abnormal flexion of the upper extremities and extension of the lower extremities?

Decorticate

Which activity should be avoided in clients with increased intracranial pressure (ICP)?

Enemas

A client is receiving hypothermic treatment for uncontrolled fever related to increased intracranial pressure (ICP). Which assessment finding requires immediate intervention?

Shivering

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. How should the nurse interpret the CPP value?

The CPP is low.

A client with head trauma develops a urine output of 300 ml/hr, dry skin, and dry mucous membranes. Which of the following nursing interventions is the most appropriate to perform initially? a.) Evaluate urine specific gravity b.) Anticipate treatment for renal failure c.) Provide emollients to the skin to prevent breakdown d.) Slow down the IV fluids and notify the physician

a.) Evaluate urine specific gravity Rationale: Urine output of 300 ml/hr may indicate diabetes insipidus, which is a failure of the pituitary to produce anti-diuretic hormone. This may occur with increased intracranial pressure and head trauma; the nurse evaluates for low urine specific gravity, increased serum osmolarity, and dehydration. There's no evidence that the client is experiencing renal failure. Providing emollients to prevent skin breakdown is important, but doesn't need to be performed immediately. Slowing the rate of IV fluid would contribute to dehydration when polyuria is present.

This was in notes: remember epidural hematoma is (uncal herniation) A client is admitted to the ER for head trauma is diagnosed with an epidural hematoma. The underlying cause of epidural hematoma is usually related to which of the following conditions? a.) Laceration of the middle meningeal artery b.) Rupture of the carotid artery c.) Thromboembolism from a carotid artery d.) Venous bleeding from the arachnoid space

a.) Laceration of the middle meningeal artery Rationale: Epidural hematoma or extradural hematoma is usually caused by a laceration of the middle meningeal artery. An embolic stroke is a thromboembolism from a carotid artery that ruptures. Venous bleeding from the arachnoid space is usually observed with subdural hematoma

A patient with a traumatic brain injury is in need of fluid replacement therapy to maintain a systole blood pressure of at least 90 mm Hg. The nurse realizes that the best fluid replacement for this patient would be: a.) Normal saline. b.) D5W c.) D5 1/2 0.9% NS d.) 0.45% NS

a.) Normal saline. Rationale: A systolic blood pressure less than 90 mm Hg in a patient with a traumatic brain injury is a predictor of a poor outcome. Initial management usually involves assuring that the patient is hydrated. Isotonic crystalloids such as 0.9% saline or Ringer's solution are most commonly used. Normal Saline is preferred because it is inexpensive, iso-osmolar and has no free water. #2 and #4 are not correct. In general, the use of hypotonic crystalloids, such as D5W or 0.45% normal saline is avoided because of the potential for worsening cerebral edema. #3 is not correct. D51/2 NS is hypertonic and will draw fluid from the cells & interstial tissue into the vascular space. This could worsen cerebral edema.

The nurse is caring for a client with a closed head injury. Which of the following would contribute to intracranial hypertension? a.) hypoventilation b.) elevating the head of the bed c.) hypernatremia d.) quiet darkened environnen

a.) hypoventilation * think of c02 Rationale: Hypoventilation leads to vasodilation and increased intracranial pressure.

A client admitted to the hospital with a subarachnoid hemorrhage has complaints of severe headache, nuchal rigidity, and projectile vomiting. The nurse knows lumbar puncture (LP) would be contraindicated in this client in which of the following circumstances? a.) Vomiting continues b.) Intracranial pressure (ICP) is increased c.) The client needs mechanical ventilation d.) Blood is anticipated in the cerebralspinal fluid (CSF)

b.) Intracranial pressure (ICP) is increased Rationale: Sudden removal of CSF results in pressures lower in the lumbar area than the brain and favors herniation of the brain; therefore, LP is contraindicated with increased ICP. Vomiting may be caused by reasons other than increased ICP; therefore, LP isn't strictly contraindicated. An LP may be preformed on clients needing mechanical ventilation. Blood in the CSF is diagnostic for subarachnoid hemorrhage and was obtained before signs and symptoms of ICP.

NCLEX QUESTIONS In conducting a primary survey on a trauma patient, which of the following is considered one of the priority elements of the primary survey? a.) Complete set of vital signs b.) Palpation and auscultation of the abdomen c.) Brief neurologic assessment d.) Initiation of pulse oximetry

c.) Brief neurologic assessment Rationale: A brief neuro assessment to determine the LOC and pupil reaction is part of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse oximetry are considered part of the secondary survey.

While cooking, your client couldn't feel the temperature of a hot oven. Which lobe could be dysfunctional? a.) Frontal b.) Occipital c.) Parietal d.) Temporal

c.) Parietal Rationale: The parietal lobe regulates sensory function, which would include the ability to sense hot or cold objects. The frontal lobe regulates thinking, planning, and judgment the occipital lobe is primarily responsible for vision function. The temporal lobe regulates memory.

For a male client with suspected increased intracranial pressure (ICP), a most appropriate respiratory goal is to: a.) Prevent respiratory alkalosis. b.) Lower arterial pH. c.) Promote carbon dioxide elimination. d.) Maintain partial pressure of arterial oxygen (PaO2) above 80 mm Hg

c.) Promote carbon dioxide elimination. Rationale: The goal in treatment is to prevent acidemia by eliminating carbon dioxide.

Which of the following signs and symptoms of increased ICP after head trauma would appear first? a.) Bradycardia b.) Large amounts of very dilute urine c.) Restlessness and confusion d.) Widened pulse pressure

c.) Restlessness and confusion Rationale: The earliest symptom of elevated ICP is a change in mental status. Bradycardia, widened pulse pressure, and bradypnea occur later. The client may void large amounts of very dilute urine if there's damage to the posterior pituitary.