Pt post craniectomy has nrsing dx impaired phys mblty r/t decreased LOC and weakness, what do?

perform range-of-motion (ROM) exercises every 4 hours.

What statement by pt being d/c from the ED after a concussion should rn address

I am going to drive home and go to bed

Pt dx w a gsw to head in decorticate whennurse applies pain 3hrs ltrWhat data shows improvement

Purposeless movement in response to painful stimuli

Pt w basal skull Fx w raccoon eyes and clear drainage from nose. RN shouldquestion which order?

Insert nasogastric tube to low suction

Which info about a pt who is hospitalized after a TBI requires the most rapid action by RN?

Intracranial pressure of 18 mm Hg

Pt dx w a closed head injury and in a coma. Intervention to prevent immobility complications?

Position the client with the HOB elevated at intervals

Pt fellhas laceration in occiptal areabeen closed w steristrips what s/s justify moving pt toER

A weak pulse, shallow respirations, and cool pale skin

Pt has increased ICP and ventriculostomy after head injury. UAP can do what?

Check capillary blood glucose level every 6 hours.

What is most important to report to MD in a patient with basilar skull fx

Temperature of 101.4° F (38.6° C)

Pt w closed head injury has clear fluid from nose Which action shouldthe nurse implement first

Test the drainage for presence of glucose

pt has a head injury and fx arm after being assaulted. Which assessment info most worrying?

The patient is more difficult to arouse.

Which client should the nurse assess first after receiving the shift report?

45yo admitted w blunt trauma to head & GCS score of 6

Family of pt w tbi asks function of ventriculostomy used to monitor ICP. RN best response?

Ithas multiple benefits including CSF drainage

Pt admitted w diffuse axonal injury has BP 106/52 and ICP 14. What should the nurse do first?

Report the BP and ICP to the health care provider.

Which action will the ED nurse anticipate for a pt dx w a concussion w/o loss of consciousness?

Provide d/c instructions about monitoring neurologic status

Which pt should the RN assess first?

Pt w right pupil 10mm and unresponsive to light

Pt w possible TBI admitted to ED. What is most important to report to MD

The patient takes warfarin (Coumadin) daily.

Suspected epidural hematoma admitted to ED. What should RN do?

Prepare the patient for craniotomy.

Which finding for a pt with a head injury should the nurse report immediately to the MD?

Pale yellow urine output is 1200 mL over the last 2 hours.

client w severe closed head injury. Which data support That the client is brain dead

no Eye activity when the cold caloric test is performed

client dx w closed head injury admitted to rehab. Which med order with the nurse question

An intravenous osmotic diuretics

Pt w possible cerebral edema has Na+ level 116 & dcrsng LOC c/o a headache Nurse do what first

Administer IV 5% hypertonic saline

Nurse witnesses a jetski accident and the pt not responding to verbal stimuli. Do which first?

Stabilize the clients cervical spine

After suctioning the nurse notes that the ICP for a pt w a TBI increased from 14 to 17. Do 1st?

Ensure that the patient's neck is in neutral position.

Pt unconscious w ineffective cerebral tissue perfusion. Do which nursing intervention?

Keep the head of the bed elevated to 30 degrees.

Pt w TBI secondary to a MVA being d/c from rehab after3mo has cog deficits Most realistic goal?

able to focus and stay on task for 10 minutes

most appropriate pt for the ICU charge nurse to assign toaRN who has floated from the med unit?

Pt receiving IV antibiotics for meningococcal meningitis

Admission vs for TBI pt BP 128/68 HR 110 RR 26. Which vs taken 1 hr ltr will be of most concern

Blood pressure 154/68, pulse 56, respirations 12

nurse is caring for a Pt dx w epidural hematoma. Which nursing interventions not to implement

Maintain the head of the bed at 60 degrees and suction q2h

Unconscious pt admitted to ED with a head injury &pt family at bedside asks many ?s. What do?

Allow fam to stay and briefly explain procedures

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MTC NUR 237 Head injury

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Questions 40

Answers

1
Pt dx w mild concussion being discharged what should the nurse teach the clients spouse
observe frequently for hypervigilance
offer the client food every 3 to 4 hours
wake the client every 2 hours
monitor for increased intracranial pressure
2
Pst evacuation of epidural hematoma ICP being monitored w intraventricular cath RN report what?
MAP 90
HR 102
Temp 101.6 F
ICP 15
3
Pt post craniectomy has nrsing dx impaired phys mblty r/t decreased LOC and weakness, what do?
turn and reposition the patient side to side every 2 hours.
position the bed flat and log roll to reposition the patient
perform range-of-motion (ROM) exercises every 4 hours.
cluster nursing activities to allow longer rest periods
4
What statement by pt being d/c from the ED after a concussion should rn address
I do not even remember being in an accident.
I can take acetaminophen (Tylenol) for my headache
I will return if I feel dizzy or nauseated
I am going to drive home and go to bed
5
RN admitting patient who has a right frontal lobe tumor would expect the patient may have
difficulty swallowing.
right-sided weakness.
expressive aphasia.
impaired judgment.
6
Pt dx w a gsw to head in decorticate whennurse applies pain 3hrs ltrWhat data shows improvement
Decerebrate posturing when painful stimuli are applied
Purposeless movement in response to painful stimuli
Pupils 6 mm in size and nonreactive to painful stimuli
flaccid paralysis in all four extremities.
7
Pt brought to ED after being found unconscious on floor. What should RN do first?
Palpate the head for hematoma or bony irregularities.
Check oxygen saturation.
Verify Glasgow Coma Scale (GCS) score.
Assess pupil reaction to light.
8
Pt w basal skull Fx w raccoon eyes and clear drainage from nose. RN shouldquestion which order?
Apply cold packs intermittently to face
Insert nasogastric tube to low suction
Keep the head of bed elevated
Turn patient side to side every 2 hours
9
Which info about a pt who is hospitalized after a TBI requires the most rapid action by RN?
Cardiac monitor shows sinus tachycardia at 128 beats/minute
Pressure of oxygen in brain tissue (PbtO2) is 20-40 mm Hg
Intracranial pressure of 18 mm Hg
Cerebrospinal fluid (CSF) drainage of 25 mL/hour
10
Pt dx w a closed head injury and in a coma. Intervention to prevent immobility complications?
Turn the client every shift and massage bony prominences
Explain all procedures to the client before performing them.
Position the client with the HOB elevated at intervals
Performed active range of motion exercises every 4 hours
11
Pt fellhas laceration in occiptal areabeen closed w steristrips what s/s justify moving pt toER
A 4 centimeters area of bright red drainage on the dressing.
Complaints of a headache that's resolved with medication.
Pupils with PERRLA
A weak pulse, shallow respirations, and cool pale skin
12
Pt has increased ICP and ventriculostomy after head injury. UAP can do what?
Turn and reposition the patient every 2 hours.
Document intracranial pressure every hour.
Monitor cerebrospinal fluid color and volume hourly.
Check capillary blood glucose level every 6 hours.
13
What is most important to report to MD in a patient with basilar skull fx
Temperature of 101.4° F (38.6° C)
Bilateral periorbital ecchymosis
Large contusion behind left ear
Complaint of severe headache
14
Pt experiences a TBI. Which finding indicates damage to the upper motor neurons?
Absent reflexes
Trousseau Sign
Flaccid muscles
Babinski response
15
Pt w closed head injury has clear fluid from nose Which action shouldthe nurse implement first
Notify the health-care provider immediately
Prepare to administer an antihistamine
Place 2x2 Gauze under the nose to collect drainage
Test the drainage for presence of glucose
16
pt has a head injury and fx arm after being assaulted. Which assessment info most worrying?
The apical pulse is slightly irregular.
The patient complains of a headache.
The blood pressure (BP) increases to 140/62 mm Hg.
The patient is more difficult to arouse.
17
Which client should the nurse assess first after receiving the shift report?
22 yo male client dx w concussion &C/o someone waking himq2h
36yo fem admitted w c/o left sided weakness scheduled forMRI
45yo admitted w blunt trauma to head & GCS score of 6
62yo client diagnosed with CVA who has expressive aphasia.
18
Family of pt w tbi asks function of ventriculostomy used to monitor ICP. RN best response?
It helps check for alterations in CPP
This system is complex and its managed by skilled staff
Ithas multiple benefits including CSF drainage
It helps show whether blood flow to the brain is adequate
19
Pt admitted w diffuse axonal injury has BP 106/52 and ICP 14. What should the nurse do first?
Elevate the head of the patient's bed to 60 degrees.
Report the BP and ICP to the health care provider.
Continue to monitor the patient's vital signs and ICP.
Document the BP and ICP in the patient's record.
20
Pt admitted with a Dx of closed head injury. Which nursing intervention has priority
Assess nurological status
Monitor pulse, respiration, and blood pressure
Maintain an adequate airway.
Initiate an intravenous access.
21
Which action will the ED nurse anticipate for a pt dx w a concussion w/o loss of consciousness?
Transport the patient to radiology for MRI
Transfer pt to the neuro unit for 24 hours of observation
Coordinate the transfer of the patient to the operating room
Provide d/c instructions about monitoring neurologic status
22
Which pt should the RN assess first?
Pt who lost consciousness for a few sec after a fall
Pt w cranial x-ray shows a linear skull fracture
Pt with GCS 13
Pt w right pupil 10mm and unresponsive to light
23
Pt w possible TBI admitted to ED. What is most important to report to MD
The patient is unable to remember the accident.
The patient complains of a severe dull headache.
The patient's blood pressure is 162/94 mm Hg.
The patient takes warfarin (Coumadin) daily.
24
Suspected epidural hematoma admitted to ED. What should RN do?
Administer IV furosemide (Lasix).
Type and crossmatch for blood transfusion.
Prepare the patient for craniotomy.
Initiate high-dose barbiturate therapy.
25
Which finding for a pt with a head injury should the nurse report immediately to the MD?
LICOX brain tissue oxygenation catheter shows PbtO2 of 38
Ventriculostomy drained 40 mL of CSF in the last 2 hours
Pale yellow urine output is 1200 mL over the last 2 hours.
Intracranial pressure is 16 mm Hg when patient is turned.
26
client w severe closed head injury. Which data support That the client is brain dead
no Eye activity when the cold caloric test is performed
head is turned to the right, the eyes turn to the righT
the EEG has identifiable waveforms
Pt assumes decorticate posturing whn painful stimuli applied
27
client dx w closed head injury admitted to rehab. Which med order with the nurse question
An oral anticonvulsant
A subcutaneous anti coagulant
An intravenous osmotic diuretics
An oral proton pump inhibitor.
28
Pt w possible cerebral edema has Na+ level 116 & dcrsng LOC c/o a headache Nurse do what first
Administer acetaminophen 650mg po
Send patient for CT
Draw blood for ABGs
Administer IV 5% hypertonic saline
29
Nurse witnesses a jetski accident and the pt not responding to verbal stimuli. Do which first?
Organize onlookers to remove the client from the lake
Stabilize the clients cervical spine
Assess the clients loc.
Perform a head to toe assessment to determine injuries
30
After suctioning the nurse notes that the ICP for a pt w a TBI increased from 14 to 17. Do 1st?
Document the increase in intracranial pressure.
Ensure that the patient's neck is in neutral position.
Notify the health care provider about the change in pressure
Increase the rate of the prescribed propofol infusion
31
Pt unconscious w ineffective cerebral tissue perfusion. Do which nursing intervention?
Keep the head of the bed elevated to 30 degrees.
Encourage coughing and deep breathing.
Cluster nursing interventions to provide rest periods.
Position the patient with knees and hips flexed.
32
TBI pt responds to nailbed pressure w internal rotation adduction flexion of arms called
decerebrate posturing.
flexion withdrawal.
localization of pain.
decorticate posturing.
33
Pt w TBI secondary to a MVA being d/c from rehab after3mo has cog deficits Most realistic goal?
regain power and bladder control
Will return to work within 6mo
able to focus and stay on task for 10 minutes
able to dress self without assistance
34
most appropriate pt for the ICU charge nurse to assign toaRN who has floated from the med unit?
Pt receiving IV antibiotics for meningococcal meningitis
Pt w up ICP receiving hyperventilation therapy
Pt admitted w skull fracture and craniotomy the previous day
Pt with ICP monitoring after a head injury last week
35
Admission vs for TBI pt BP 128/68 HR 110 RR 26. Which vs taken 1 hr ltr will be of most concern
Blood pressure 154/68, pulse 56, respirations 12
Blood pressure 148/78, pulse 112, respirations 28
Blood pressure 110/70, pulse 120, respirations 30
Blood pressure 134/72, pulse 90, respirations 32
36
nurse is caring for a Pt dx w epidural hematoma. Which nursing interventions not to implement
Maintain the head of the bed at 60 degrees and suction q2h
Administer mild sedative
Administer stool softeners daily
Ensure that pulse oximeter reading is higher than 93 percent
37
Pt with TBI has BP 130/76 and ICP 20. What is CPP?
71
72
73
74
38
Gave IV mannitol (Osmitrol) to an unconscious pt. Monitor what for med effectiveness?
H&H
O2 sat
ICP
BP
39
Unconscious pt admitted to ED with a head injury &pt family at bedside asks many ?s. What do?
Ask the fam to go to waiting room until 1st asmnt is done
Allow fam to stay and briefly explain procedures
Refer family to counseling services d/t anxiety
Call the fam spiritual advisor to take them to chapel.
40
New RN caring for pt post craniotomy for resection of braintumor When should chargeRN intervene
New RN assesses neurologic status every hour.
New Rn elevates HOB 30 degrees
New RN gives analgesic before turning
New RN suctions q2h

MTC NUR 237 Head injury Flashcards | StudBud