HESI CS - Traumatic Brain Injury

Which components are measured by the GCS? a. Verbal response, motor response, and eye opening. b. Seizure activity, muscle strength, and range of motion. c. Gag reflex, Patellar reflex, and Babinski reflex. d. Pupillary response, visual field, and visual acuity.

A The GCS measures responses that are spontaneous and completely oriented to responses only from noxious stimuli to no response at all. The client is observed for abnormal decorticate (flexor) and decerebrate (extensor) posturing as part of the motor response to a stimulus.

This score indicates which finding to the nurse? a. Resolving neurologic condition. b. Declining neurologic condition. c. Loss of consciousness. d. Poor chance of recovery.

B The GCS numerical rating ranges from 3 to 15, with 15 being the best rating, and 3 indicating a poor prognosis and high mortality rate. Any decrease of two points or more is considered significant, requiring notification of the physician.

What is the Glasgow Coma Scale rating obtained in this assessment? Enter the numerical value only. If rounding is necessary, round to the whole number.)

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Which nursing intervention should be initiated to prevent increased ICP for this client? a. Keep neck flexed. b. Keep the head of the bed elevated at 30 degrees. c. Perform passive range of motion on extremities. d. Suction airway as needed for at least 15 seconds each time.

B Activities such as performing a Valsalva maneuver, coughing, and vomiting should be prevented, since they may cause an increase in ICP. In addition, the client should be positioned with the head of the bed elevated about 30 degrees, and neck flexion and extension should be avoided.

Which sign is the most important early indicator of increasing ICP? a. Changes in extraocular eye movement. b. Changes in vital signs. c. Change in level of consciousness. d. Vomiting.

C A change in LOC is the single most significant indicator of deterioration in neurologic function.

What is the best response by the nurse? a. Let me close the door so that we can talk privately. b. Anything you tell me is completely confidential. c. As a nurse, I must document everything that happens between us and other people have access to the information. d. While I can keep many things confidential, there are instances where I may have to share some information.

D Since the client's parents are legally responsible for his care, knowledge which is harmful may need to be shared by the nurse.

The nurse gives the furosemide IVP very slowly. Which side effects can result from IV furosemide? (Select all that apply. One, some, or all options may be correct.) a. Severe dehydration. b. Hypokalemia. c. Ototoxicity. d. Hyponatremia. e. Hypochloremia. f. Thrombosis.

A, B, C, D, E, F Furosemide can produce excessive loss of sodium, chloride, and water. Severe dehydration can result. Signs of evolving dehydration include dry mouth, unusual thirst, and oliguria (scanty urine output). Impending dehydration can also be anticipated from excessive loss of weight. If dehydration occurs, furosemide should be withheld. Potassium is lost through increased secretion in the distal nephron. If serum potassium falls below 3.5 mEq/L, fatal dysrhythmias may result. The ability to impair hearing is unique to the loop diuretics. Diuretics in other classes are not ototoxic. Because of the risk of hearing loss, caution is needed when loop diuretics are used in combination with other ototoxic drugs (e.g., aminoglycoside antibiotics). Use of furosemide can produce excessive loss of sodium, chloride, and water. Severe dehydration can result. Dehydration can promote hypotension, thrombosis, and embolism.

The nurse prepares to administer furosemide 20 mg IVP. The drug availability is furosemide 10 mg/mL. How many mL should the nurse administer IVP? (Enter numerical value only. If rounding is necessary, round to the whole number.) _______ mL

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Which documentation indicates that the expected outcome of the mechanical ventilation was achieved? a. Client exhibits no signs or symptoms of increased ICP. b. Client's ABG results are within normal limits (WNL). c. Client's electrolytes are within normal limits (WNL). d. Client remains afebrile and sitting upright in the bed.

A The goal of hyperventilation is to maintain cerebral oxygenation and prevent an increase in ICP by maintaining the PCO2 at a low normal level.

The nurse notes in the electronic health record the client's assessment findings related to the diagnosis of meningitis. Which of these findings is indicative of meningitis? (Select all that apply. One, some, or all options may be correct.) a. Fever and chills. b. Headache. c. Nuchal rigidity. d. Irritability. e. Seizures. f. Photophobia.

A, B, C, D, F Clinical manifestations of meningitis include fever, chills, nuchal rigidity (neck stiffness), photophobia (light sensitivity), phonophobia (noise sensitivity), headache, myalgia (muscle aches), nausea, and vomiting. Confusion and altered consciousness may be present.

The HCP prescribes the following:Sodium chloride 0.9% at 30 mL/hour.20% mannitol IVPB every 12 hours.Furosemide 20 mg IVP following mannitol.Dexamethasone 4 mg IVP every 6 hours.Phenytoin 100 mg IVP every 8 hours.Which medications can be mixed with the other medications? (Select all that apply. One, some, or all options may be correct.) a. Mannitol. b. Furosemide. c. Dexamethasone. d. Phenytoin. e. Sodium chloride 0.9%

A, B, C, E Mannitol - This is an osmotic diuretic that is compatible in a y-site with furosemide and dexamethasone. Furosemide is a loop diuretic that is compatible in a y-site with mannitol and dexamethasone. Dexamethasone - This is a glucocorticoid and is compatible in a y-site with mannitol and furosemide. Sodium chloride 0.9% - This is compatible with all of the other medications listed.

The unconscious client is hurriedly brought into the ED, and several nurses begin the assessments. Which assessment techniques are used to determine if this client has a traumatic brain injury? (Select all that apply. One, some, or all options may be correct.) a. Assess for tinnitus or hearing difficulty. b. Observe the area behind the client's ears. c. Observe the area around the client's eyes. d. Test the client's ability to follow complex directions. e. Check the client's ear cavity for leaking fluid. Submit

A, B, C, E Tinnitus and hearing difficulties are manifestations of a basilar skull fracture. Battle's sign refers to ecchymosis behind the ears, and it is a common manifestation of a traumatic brain injury. Periorbital ecchymosis, also called "raccoon eyes," is a common manifestation of a basilar skull fracture, along with a positive Battle's sign. Otorrhea is cerebrospinal fluid leakage from the ear and generally confirms that the fracture has traversed the dura.

Which interventions must be performed by the nurse? (Select all that apply. One, some, or all options may be correct.) a. Obtain an oxygen saturation level on a postoperative client. b. Assess an older adult client with dyspnea. c. Ambulate a client in the hallway. d. Assist a client who has vomited to change the hospital gown. e. Provide discharge instructions to a client ready to go home.

A, B, E This responsibility can be performed by the UAP, although the nurse will need to perform additional assessment and analysis of the respiratory status. The nurse should be assigned this responsibility. Of the four tasks, this requires the highest level of expertise to assess the client's current condition and response to the treatment. (Always remember ABCs.) Discharge teaching must be performed by the nurse. This intervention may not be delegated to the UAP.

Before responding to the media, which information is of primary concern to the supervisor? a. Does the reporter work for a reputable news agency? b. Has the client signed a release of information? c. How did the leak occur? d. Have the nurses been reprimanded?

B All clients have the right to confidentiality. It is the responsibility of the nurse to safeguard client information.

Which additional nursing priority is important to include when planning the client's care during this period? a. Fluid overload. b. Mobility impairment. c. Possible constipation. d. Difficulty coping.

B Clients with meningitis may experience a prolonged recovery time and may experience hemiparesis, dysphasia, and hemianopsia.

Which statement by the client indicates a clear understanding of the anticipated course of events? a. I'll be as doing everything I used to do very soon. b. I will prevent the pressure in my brain from increasing. c. I may never be back to my former self. d. I will never be able to live on my own.

C For the most part, people who experience a mild to severe traumatic brain injury are never the same again. Long-term effects may include altered cognitive, motor, sensory, or emotional functioning. Progressive recovery generally occurs for the first six months before a plateau is reached, and some problems, such as post-injury seizures, may not occur until several years after the injury.

Which nursing intervention should the nurse include when administering the mannitol? a. Monitor hematocrit and hemoglobin levels. b. Titrate to produce urine output of 20 mL/hr. c. Administer by IV infusion undiluted. d. Administer via a central line.

C Mannitol is a hypertonic solution used to reduce intracranial pressure. Mannitol is often given with a diuretic, such as furosemide. It should be administered undiluted, but through a filter to prevent the administration of any particulates.

Which is the most significant behavior change in adolescent behavior needed to reduce traumatic brain injuries? a. Never use an electronic device while driving. b. Minimize distractions while driving, including passengers. c. Never ride with someone who has been drinking alcohol. d. Drive only during daylight hours.

C Sixty percent of all head injuries are alcohol-related. The vast majority of these occur between the ages of 10 to 39, with the peak incidence between the ages of 15 to 24.

Which arterial blood gas (ABG) results would be desirable for a client with increased ICP? a. PO2 of 90 and PCO2 of 50. b. PO2 of 98 and PCO2 of 45. c. PO2 of 97 and PCO2 of 35. d. PO2 of 88 and PCO2 of 18.

C The PO2 should be maintained close to 100 to promote cerebral oxygenation. The PCO2 indicates a low normal level, which will prevent the vasodilation that occurs with hypercapnia. Studies have shown that aggressive hyperventilation may contribute to focal cerebral ischemia.

Which statement about adolescents should guide the nurse's response? a. Adolescents need to create or nurture things that will outlast them. b. Adolescents need to form loving relationships with other people. c. Adolescents need to develop a sense of self and personal identity. d. Adolescents need to assert control and power over their environment.

C The adolescent becomes less reliant on the family and much more reliant on the peer group for a sense of identity.

What is the nurse's best response to the client's refusal to see friends? a. Your friends may be able to help you cope better to the situation. b. It might be a good idea to wait a while before you visit with your friends. c. You sound concerned about how your friends will react when they see you. d. How do you think your friends will feel if you refuse to see them?

C This is a therapeutic response, which clarifies the client's concerns and allows for further communication.

What method can the nurse use to determine if the drainage is CSF? a. Test the fluid for glucose in the drainage. b. Observe for blood and exudate in the drainage. c. Observe for a halo around a spot of drainage. d. Note the amount and color of the drainage.

C When a drop of the drainage is placed on a white dressing, the CSF will separate from the blood and form a "halo" around the blood. Other measures the nurse can use include observing the appearance of the drainage and using a dextrostick to assess for the presence of glucose in the drainage. CSF is clear. However, the CSF may be mixed with blood, so appearance alone may not be a true indicator of CSF. CSF contains glucose, unlike normal nasal drainage. However, a false positive for glucose may be obtained if the CSF is mixed with blood, since blood also contains glucose.

Which intervention should the nurse initiate? a. Postpone going to the client's room for one hour. b. Instruct the UAP to leave him alone for a few hours. c. Administer an analgesic for his headache. d. Assess vital signs and neurological status.

D The client is exhibiting symptoms of meningitis, a serious complication requiring immediate medical and nursing intervention. The nurse should gather additional assessment data, such as vital signs and neurologic status, and then notify the healthcare provider.

This method of administration is chosen to reduce the risk of which possible problem? a. Medication error. b. Allergic reaction. c. Extravasation. d. Fluid overload.

D The client with increased ICP requires very careful administration of IV fluids to avoid fluid volume overload, which would increase ICP. Using an infusion pump will reduce the risk of fluid overload.

The client is awake and requests something for a headache. Which medication is best for the nurse to administer? a. Morphine sulfate. b. Oxycodone/aspirin. c. Hydrocodone/acetaminophen. d. Acetaminophen.

D This is the best choice, because acetaminophen is a non-opioid analgesic, and it will not cause CNS depression.