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Nursing Management of Head Injuries Flashcards | StudBud
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Nursing Management of Head Injuries
Nursing Management of Head Injuries
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Level 4 nursing students
Flashcards
26 cards
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Practice quiz
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Questions
26
Answers
1
S.A. calls her HCP 10 days later c/o h/a's, difficulty concentrating, & trouble recalling things. The RN explains:
These signs are concerning, but unless she has a fever it's not serious.
These signs are common, she should increase her H2O intake to prevent DI.
These signs are concerning, she must go to the ED immediately!
These signs are common after a concussion and can last up to 3 months.
2
The S & S of an Acute SDH are similiar to those of increased ICP.
True
False
3
As the RN, you recognize the collaborative care of L.J. will include: (SATA)
Maintaining normothermia
Antibiotics until meningitis is ruled out.
Monitoring for Intracerebral hemorrhage
Preventing complications of immobility
Preventing secondary injury by controlling ICP.
LMW heparin to prevent VTE complications
4
The most common etiologies for traumatic brain injuries include: (SATA)
Sports related
Blunt trauma
Falls
Fire arms
MVC
5
In this situation, the DAP therapy J.I. has been taking can: (SATA)
Is not a concern at all and should be continued due her a. Fib
Decrease the size of the contusion.
Increase the risk of mortality
Increase the severity of the injury
Increase the size of the contusion, causing it to "blossom"
6
B.B. is a 78 y/o female, admitted w/ a chronic subdural hematoma. As the RN, you know: (SATA)
Chronic SDH's develop over several weeks.
Chronic SDH's are common in elder and alcoholics.
Chronic SDH's have more focal s & s than s & s of increased ICP.
The s & s can mimic a stroke or dementia.
Occurs within 2 to 3 days
Occurs within 24 - 48 hours
7
Classic s & s of an epidural hematoma includes a period of unconsciousness, lucidity, & then a sudden decrease in LOC.
False
True
8
The client w/ a TBI has a change in his GCS from 10 to 12 in the past 2 hrs. As the RN, you should:
Document the assessment and continue to monitor
Assess for abnormal reflexes
Assess for signs and symptoms of Diabetes insipidus
Call the HCP STAT!
9
Diagnostics for TBI include(s): (SATA)
Cervical spine x-ray series
Toxicology screen
Coagulation panel
Lumbar puncture
CT head scan w/o contrast
10
Examples of focal brain injuries includes: (SATA)
Subdural hematomas
Concussion
Intracerebral hematomas
Epidural hematoma
Subarachnoid hemorrhages
11
Which statements re: the pathophysiology of a Diffuse Axonal injury is/are true? (SATA)
Twisting and shearing of the dendrites
Swelling & disconnection of the axons
Changes in the function of the axons
Primarily effects the subcortical white matter of the brain
12
While planning the d/c teaching for your client recovering from a TBI, the RN must include the "no" policies: (SATA)
No unsupervised smoking
No use of firearms
No driving or use of heavy equipment
No ETOH drinking
13
T.R. begins to have a small amount serosanguinous dripping from his Rt nare. What is the priority intervention?
Perform a glucostix test
Insert a nasal tampon into the right nare.
Perform a halo test
Instruct T.R. to blow his nose forcefully.
14
What are the assessment findings with a Basilar Skull fracture? (SATA)
Tinnitus
Ataxia
Racoon eyes
Otorrhea or Rhinorhea
Boggy temporal muscle
Post auricular ecchymosis (Battle sign)
15
If a client has a Glasgow Coma Score (GCS) < 10, he/she is considered to be in a comatose state.
False
True
16
Which of the following are examples of diffuse traumatic brain injuries? (SATA)
Intracerebral hemorrhages
Basilar skull fracture
Diffuse Axonal injuries
Concussion
Epidural hematoma
17
A basilar skull fracture is a linear fracture of the base of the skull.
True
False
18
Which of the following are types of Skull fractures? (SATA)
Open or Closed
Simple, Comminuted, Compound
Linear or Depressed
Vertebral
Axial
Contiguous
19
Men are twice as likely as women to sustain a traumatic brain injury.
False
True
20
T.R. begins to experience projectile vomiting w/o any c/o nausea. The RN anticipates which order from the HCP?
Keep client flat and in good alignment.
Zofran 4 mg IV push now.
Preparation of the client for emergency surgery.
Insertion of an NGT or OGT at the bedside.
21
R.P. has a left cerebral epidural hematoma. The RN in the ED should find the following on assessment of R.P. :(SATA)
Headaches
Right pupil dilation w/ sluggish response
Left pupil dilation w/ sluggish response
Nausea & Vomiting
Left sided paraplegia and parathesias
Right sided paraplegia and parathesias
22
S.A. is being d/c'd from the ED w/ a dx of a mild concussion. She should return to the E.D. if she experiences: (SATA)
Worsening headache
Palpitations
Projectile vomiting w/o nausea
Low grade fever
Hiccups
Difficulty waking the patient
23
Clinical s & s of Diffuse Axonal injury includes: (SATA)
No increase in ICP
90% will be in a persistent vegetative state
Decreased LOC
Abnormal Posturing
Signs of Global cerebral edema & may vary.
24
As the RN caring for J.I., do you agree w/ the family's decision re: J.I.'s care?
No, she doesn't meet the criteria for a Living will to be activated.
Yes but only because it's my duty to honor her wishes.
No, this is potentially reversible.
Yes, prognosis is poor.
25
As the RN, which complication(s) must you monitor for at this time? (SATA)
Infection
Sucking head wound
Hypotension & tachycardia
Cardiac dysrhythmias
Rhinorrhea
26
Usually associated w/ TBI and found w/ skull fxs, contusions are also described as a "bruising" of the brain.
True
False
