The Client with a Head Injury

Question 1

The nurse is monitoring a client with increased ICP. What indicators are the most critical for the nurse to monitor? SATA

1. Systolic BP
2. Urine output
3. breath sounds
4. cerebral perfusion pressure
5. level of pain

Answer 1

1. Systolic BP
2. cerebral perfusion pressure

Nurse must monitor these to obtain the MAP which represents the pressure needed for each cardiac cycle to perfuse the brain.

Question 2

The nurse is assessing the level of consciousness in a client with a head injury who has been unresponsive for the last 8 hours. Using the Glasgow Coma Scale, the nurse notes that the client opens the eyes only as a response to pain, responds with sounds that are not understandable, and has abnormal extension of the extremities. What should the nurse do? (score indicates coma)

1. Attempt to arouse the client
2. Reposition the client with the extremities in normal alignment
3. Chart the client’s level of consciousness as coma
4. Notify the HCP

Answer 2

3. Chart the client’s level of consciousness as coma

No need to report to the HCP since this is not a significant change from before.

Question 3

An unconscious client with multiple injuries to the head and neck arrives in the ED. What should the nurse do first?

1. Establish an airway
2. Determine the identity of the client
3. Stop bleeding from open wounds.
4. Check for a neck fracture

Answer 3

1. Establish an airway

Question 4

A client has an increased ICP of 20 mm Hg. What should the nurse do next?

1. Give the client a warming blanket
2. Administer low-dose barbiturates
3. Encourage the client to take DB to hyperventilate
4. Restrict fluids

Answer 4

3. Encourage the client to take DB to hyperventilate

Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causes vasoconstriction, which reduces CSF and BV, which are 2 important factors for reducing ICP.

Question 5

3. Encourage the client to take DB to hyperventilateThe nurse is assessing a client with increasing ICP. The nurse should notify the HCP about which early change in the client’s condition?
4. Widening pulse pressure
5. Decrease in the pulse rate
6. dilated, fixed pupils
7. decrease in LOC

Answer 5

4. decrease in LOC

This is early indicator of deterioration of the client’s neurologic status. Rest of the answer choices are later if the increased ICP is not treated.

Question 6

The nurse administers mannitol to the client with increased ICP. Which parameter requires close monitoring?

1. muscle relaxation
2. intake and output
3. widening of the pulse pressure
4. pupil dilation

Answer 6

2. intake and output

Mannitol promoted diuresis and is given primarily to pull water from the extracellular fluid. It can cause hypokalemia and may lead to muscle contractions.

Question 7

A client receiving continuous mandatory ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. What should the nurse do?

1. Count the rate to be sure that ventilations are deep enough to be sufficient
2. Notify the HCP of the client’s breathing pattern
3. Increase the rate of ventilations
4. Increase the tidal volume on the ventilator

Answer 7

2. Notify the HCP of the client’s breathing pattern

A cluster breathing is clusters of irregular breaths followed by periods of apnea on an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. So it should be notify to the HCP immediately so the treatment can begin before respirations cease.

Question 8

The nurse is planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. What should the nurse avoid when positioning the client?

1. keeping the client flat on one side or the other
2. elevating the HOB to 30 degrees
3. logrolling or turning as a unit when turning
4. keeping the neck in a neutral position

Answer 8

2. elevating the HOB to 30 degrees

It could cause herniation of the brain down onto the brain stem and spinal cord, resulting in sudden death.

Question 9

A young adult is admitted to the hospital with a head injury and possible temporal skull fracture sustained in a motorcycle accident. On admission, the client was conscious but lethargic; vital signs included temp 99F, pulse 100 bpm, RR 18, and BP 140/70. The nurse should report which changes should they occur to the HCP? SATA

1. decreasing urinary output
2. decreasing systolic bp
3. bradycardia
4. widening pulse pressure
5. tachycardia
6. increasing diastolic bp

Answer 9

3. bradycardia
4. widening pulse pressure

These changes indicate increasing ICP, which should be reported to the HCP immediately.

Question 10

A client with a head injury regains consciousness after several days. When the client first awakes, what should the nurse say to the client?

1. “I’ll get your family.”
2. “Can you tell me your name and where you live?.”
3. “I’ll bet you are a little confused right now.”
4. “You’re in the hospital. You were in an accident and unconscious.”

Answer 10

4. “You’re in the hospital. You were in an accident and unconscious.”