Week 10 Brain Injury Flashcards
The nurse has received a combative client in the emergency department after falling down a flight of stairs. Which is the nurse’s priority intervention?
A) Administer diazepam 10 mg IV over two minutes
B) With the client’s head in a neutral position, elevate the head above the bed 30°
C) Implement fall and seizure precautions
D) Assess the client’s Glasgow coma scale (GCS) score
C) Implement fall and seizure precautions
When receiving a client with an acute head injury, the nurse should start by instituting fall and seizure precautions to prevent further injury.
The nurse is creating a teaching plan for a client discharged post-head injury. Which statement(s) should the nurse include in the teaching?
A. “Recovery from a head injury may take a couple of weeks.”
B. “Another person should remain in the home with you until the recovery is complete.”
C. “Avoid any alcohol intake.”
D. “Notify your provider if you develop a severe headache.”
A. “Recovery from a head injury may take a couple of weeks.”
Instruct the client that recovery from head injury can take weeks to months following the initial injury.
C. “Avoid any alcohol intake.”
The nurse should remind clients to avoid alcohol and consult with their healthcare provider before taking any medications that can cause drowsiness. Alcohol and medications that cause drowsiness may mask symptoms associated with a worsening condition and increase the client’s risk for injury.
D. “Notify your provider if you develop a severe headache.”
The nurse should instruct clients to notify the healthcare provider of a severe headache, as this could indicate their condition is worsening.
The nurse working in the emergency department is preparing to describe a head injury to a client. Which structures might be affected by a head injury? Select all that apply.
A. Skull
B. Brain
C. Blood vessels
D. Vertebrae
E. Scalp
A. Skull
B. Brain
C. Blood vessels
E. Scalp
The nurse has described the physiology of the brain and its surrounding structures to a nursing student. Which statement by the student indicates an understanding of the teaching?
A) “The skull has two components: the cranium and the cervical spine.”
B) “The arachnoid mater is the innermost membrane wrapping around the brain and spinal cord.”
C) “The subarachnoid space is between the pia mater and dura mater.”
D) “The subarachnoid space is a thin space filled with cerebrospinal fluid that helps to cushion the brain.”
D) “The subarachnoid space is a thin space filled with cerebrospinal fluid that helps to cushion the brain.”
The nurse reviews the prescriptions for a client newly admitted to the intensive care unit with a major closed head injury. The client is receiving mechanical ventilation. Which medication should the nurse anticipate administering to decrease intracranial pressure?
A) Mannitol 0.25g/kg intravenously every 8 hours as needed
B) Acetaminophen 650 mg PR every 4 hours
C) Ceftriaxone 1 g intravenously every 12 hours
D) Phenytoin 15 mg/kg intravenously x1
A) Mannitol 0.25g/kg intravenously every 8 hours as needed
The nurse admits a client to the emergency department who fell off a ladder and is suspected of having sustained a head injury. Which diagnostic testing should the nurse prepare the client for after noting the client’s Glasgow Coma Score (GCS) is a 10?
A) Electroencephalogram (EEG)
B) Serum glucose and alcohol level
C) Cerebral angiogram
D) Computed tomography (CT) scan
A computed tomography (CT) scan helps diagnose the extent of a head injury because it can detect intracranial hematomas.
The nurse has explained the pathophysiology of head injuries on the brain and its surrounding structures to a nursing student. Which statement indicates an understanding of the information? Select all that apply.
A. “Vascular injuries include a subdural hematoma, which refers to bleeding between the dura mater and the inner surface of the skull.”
B. “Open and closed fractures may cause brain lacerations.”
C. “Intracerebral hematoma refers to bleeding within the brain tissue itself.”
D. “Concussions cause a transient disruption of blood flow to the brain that may temporarily affect the level of consciousness.”
E. “Focal brain injuries include contusions, brain lacerations, vascular injuries, and widespread damage to neuronal axons.”
F. “Brain lacerations are caused by a foreign object getting pushed into the skull, causing a tear in the brain tissue.”
G. “Closed fractures are breaks in skull bones that damage the surrounding tissue such as the scalp.”
B. “Open and closed fractures may cause brain lacerations.”
C. “Intracerebral hematoma refers to bleeding within the brain tissue itself.”
F. “Brain lacerations are caused by a foreign object getting pushed into the skull, causing a tear in the brain tissue.”
The nurse is preparing to assess a client with an acute head injury. Which signs and symptoms should the nurse correlate with the injury? Select all that apply.
A. Hemiparesis
B. Sluggish pupillary reaction to light
C. Irritability
D. Nausea and vomiting
E. Dysarthria
F. Urinary incontinence
G. Amnesia
A. Hemiparesis
B. Sluggish pupillary reaction to light
C. Irritability
D. Nausea and vomiting
E. Dysarthria
F. Urinary incontinence
G. Amnesia
The nurse teaches clients about preventing head injuries. Which information should the nurse include in the teaching? Select all that apply.
A. Workplace safety
B. Helmet use while biking
C. Consuming a low-sodium diet
D. Alcohol use
E. Regular seat belt use
A. Workplace safety
B. Helmet use while biking
D. Alcohol use
E. Regular seat belt use
The nurse is teaching about signs and symptoms of concussions. She realizes the nursing student needs further instruction when which statement is expressed?
“Vision loss can occur”
“Headache is a common symptom”
“Retrograde amnesia is common”
“Brief loss of consciousness can occur”
“Vision loss can occur”
This answer is correct because vision loss is not an expected finding in a patient with a concussion. If a client reports vision loss, then further investigations and interventions need to be completed. Common symptoms of concussion include brief loss of consciousness, retrograde amnesia, and headache.
A client comes in after being involved in a severe motor vehicle accident (MVA). What is the nurse’s priority action?
Completing a full neuro assessment
Stabilizing the cervical spine (C-spine)
Obtaining the Glasgow Coma Scale (GCS)
Obtaining a medical history
Stabilizing the cervical spine (C-spine)
This answer is correct because stabilizing the C-spine is the priority action of the nurse. If the cervical spine has been injured and it’s not stabilized, then further injury can easily happen. This can lead to worsening morbidity or even death.
The client has sustained an injury to the occipital lobe. Which assessment finding is the nursing expecting to find?
Memory impairment
Hearing difficulty
Balance and coordination issues
Impaired visual perception
Impaired visual perception
This answer is correct because the occipital lobe does control visual perception. Each lobe of the brian has an overall specific function. The function of the occipital lobe is to control sight and visual perception.
The client was involved in a motor vehicle accident and has a traumatic brain injury (TBI). Clear drainage from the ear was noted upon assessment and the client reports pain. What is the priority nursing action?
Notify the health care provider (HCP) immediately
Check the clear fluid for glucose
Perform a full neuro assessment
Administer pain medication
Check the clear fluid for glucose
This answer is correct because the nurse must first check the fluid for glucose. If the drainage from the ear does test positive for glucose then it is indicative of a CSF leak. Once it has been established the client has a CSF leak, then the HCP needs to be notified immediately.
The nurse is aware that the patient with which set of vital signs (VS) is most indicative for Cushing’s triad in a 7 year old patient?
Temperature 36.6 degrees C, HR 68, RR 22, and BP 125/60 mm/Hg
Temperature 37.8 degrees C, HR 58, RR 20, and BP 138/45 mm/Hg
Temperature 37.0 degrees C, HR 64, RR 22, and BP 100/60 mm/Hg
Temperature 37.4 degrees C, HR 90, RR 24, and BP 130/68 mm/Hg
Temperature 37.8 degrees C, HR 58, RR 20, and BP 138/45 mm/Hg
This answer is because this patient does have symptoms most concerning for Cushing’s triad including bradycardia, increased systolic pressure, and wide pulse pressure. Respirations and temperature are to be monitored but are not a part of Cushing’s triad. Those with Cushing’s triad commonly do have Cheyne-Stokes respirations.
A nurse is caring for a client with a C5 spinal injury. Which action is most important for a client with injury to the C5 spinal cord?
Encouraging the use of an incentive spirometer
Monitor for signs of infection
Monitor client’s respiratory status
Apply an abdominal binder
Monitor client’s respiratory status
This answer is correct because monitoring the client’s respiratory status will alert the nurse to changes that may indicate atelectasis or infection. An injury to C5 will sometimes require endotracheal intubation and mechanical ventilation. However, it may involve diaphragm weakness, but with the ability to breathe independently.
