HEAD INJURY Flashcards
1.A 10-year-old boy is brought to the emergency department via ambulance after he was involved in a motor vehicle collision. The patient is unconscious on arrival. Glasgow Coma Scale (GCS) score is 8. CT scan does not show any specific lesion. The patient remains unconscious for the next 7 hours. Based on these findings, which of the following is the most likely diagnosis?
a.Subdural hematoma
b.Diffuse axonal injury
c.Epidural hematoma
d.Subarachnoid hemorrhage
B
2.The presence of a skull fracture confirmed via imaging study is indicative that significant force was involved in the injury. Specific types of skull fractures can result in special risks to the patient. One of these risks includes damage to facial, acoustic, and vestibular nerve function. Fracture of which of the following structures will increase a patient’s risk of this type of damage?
a.Carotid canal
b.Parietal bone
c.Base of the occipital bone
d.Temporal bone
C
3.A patient who sustained a traumatic brain injury has impaired consciousness, Glasgow Coma Scale score of < 15, focal neurologic findings, and suspected fracture. Which of the following is the most appropriate initial imaging step?
a.CT scan
b.Magnetic resonance angiography
c.MRI
d.X-ray
A
4.The client diagnosed with a mild concussion is being discharged from the emergency department. Which discharge instruction should the nurse teach the client’s significant other?
a.Awaken the client every two (2) hours.
b.Monitor for increased intracranial pressure.
c.Observe frequently for hypervigilance.
d.Offer the client food every three (3) to four (4) hours.
A
5.The resident in a long-term care facility fell during the previous shift and has a laceration in the occipital area that has been closed with Steri-Strips. Which signs/symptoms would warrant transferring the resident to the emergency department?
a. A 4-cm area of bright red drainage on the dressing.
b.A weak pulse, shallow respirations, and cool pale skin.
c.Pupils that are equal, react to light, and accommodate.
d.Complaints of a headache that resolves with medication.
B
6.The client has sustained a severe closed head injury and the neurosurgeon is determining if the client is “brain dead.” Which data support that the client is brain dead?
a.When the client’s head is turned to the right, the eyes turn to the right.
b.The electroencephalogram (EEG) has identifiable waveforms.
c.There is no eye activity when the cold caloric test is performed.
d.The client assumes decorticate posturing when painful stimuli are applied
C
7.The client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority?
a.Assess neurological status.
b.Monitor pulse, respiration, and blood pressure.
c.Initiate an intravenous access.
d.Maintain an adequate airway.
D
8.The client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order would the nurse question?
a.A subcutaneous anticoagulant.
b.An intravenous osmotic diuretic.
c.An oral anticonvulsant.
d.An oral proton pump inhibitor.
B
9.The client diagnosed with a gunshot wound to the head assumes decorticate posturing when the nurse applies painful stimuli. Which assessment data obtained three (3) hours later would indicate the client is improving?
a.Purposeless movement in response to painful stimuli.
b.Flaccid paralysis in all four extremities.
c.Decerebrate posturing when painful stimuli are applied.
d.Pupils that are 6 mm in size and nonreactive on painful stimuli.
A
10.The nurse is caring for a client diagnosed with an epidural hematoma. Which nursing interventions should the nurse implement?Select all that apply.
a.Maintain the head of the bed at 60 degrees of elevation.
b.Administer stool softeners daily.
c.Ensure that pulse oximeter reading is higher than 93%.
d.Perform deep nasal suction every two (2) hours.
e.Administer mild sedatives.
B,C,E
11.The client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implementfirst?
a. Notify the health-care provider immediately.
b.Prepare to administer an antihistamine.
c.Test the drainage for presence of glucose.
d.Place 2 × 2 gauze under the nose to collect drainage.
C
12.The client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as “high risk for immobility complications.” Which intervention would be included in the plan of care?
a.Position the client with the head of the bed elevated at intervals.
b.Perform active range-of-motion exercises every four (4) hours.
c.Turn the client every shift and massage bony prominences.
d.Explain all procedures to the client before performing them.
A
13.The nurse is monitoring a client with
increased intracranial pressure (ICP). What indicators are the most critical for the nurse to monitor? Select all that apply.
a.Systolic blood pressure.
b.Urine output.
c.Breath sounds.
d.Cerebral perfusion pressure.
e.Level of pain.
A,D
14.An unconscious client with multiple injuries
arrives in the emergency department. Which nursing intervention receives the highest priority?
a.Establishing an airway.
b.Replacing blood loss.
c.Stopping bleeding from open wounds.
d.Checking for a neck fracture.
A
15.A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor?
a.Unequal pupil size.
b.Decreasing systolic blood pressure.
c.Tachycardia.
d.Decreasing body temperature.
A
