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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
27 terms
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StudBud Administration
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Level 4 nursing students
Flashcards
27 cards
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Practice quiz
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Questions
27
Answers
1
As the RN caring for J.I., do you agree w/ the family's decision re: J.I.'s care?
Yes but only because it's my duty to honor her wishes.
No, this is potentially reversible.
Yes, prognosis is poor.
No, she doesn't meet the criteria for a Living will to be activated.
2
Examples of focal brain injuries includes: (SATA)
Intracerebral hematomas
Epidural hematoma
Subdural hematomas
Concussion
Subarachnoid hemorrhages
3
Usually associated w/ TBI and found w/ skull fxs, contusions are also described as a "bruising" of the brain.
False
True
4
What are the assessment findings with a Basilar Skull fracture? (SATA)
Otorrhea or Rhinorhea
Boggy temporal muscle
Ataxia
Racoon eyes
Tinnitus
Post auricular ecchymosis (Battle sign)
5
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)
Palpitations
Projectile vomiting w/o nausea
Worsening headache
Low grade fever
Difficulty waking the patient
Hiccups
6
Classic s & s of an epidural hematoma includes a period of unconsciousness, lucidity, & then a sudden decrease in LOC.
False
True
7
The Glasgow Coma Score (GCS) is an assessment of: (SATA)
Visual field cuts
Motor response
Swallowing ability
Phonation
Eye opening
Verbal response
8
Which statements re: the pathophysiology of a Diffuse Axonal injury is/are true? (SATA)
Swelling & disconnection of the axons
Changes in the function of the axons
Primarily effects the subcortical white matter of the brain
Twisting and shearing of the dendrites
9
T.R. begins to experience projectile vomiting w/o any c/o nausea. The RN anticipates which order from the HCP?
Preparation of the client for emergency surgery.
Insertion of an NGT or OGT at the bedside.
Keep client flat and in good alignment.
Zofran 4 mg IV push now.
10
Clinical s & s of Diffuse Axonal injury includes: (SATA)
90% will be in a persistent vegetative state
Abnormal Posturing
No increase in ICP
Signs of Global cerebral edema & may vary.
Decreased LOC
11
As the RN, you recognize the collaborative care of L.J. will include: (SATA)
Preventing complications of immobility
LMW heparin to prevent VTE complications
Maintaining normothermia
Antibiotics until meningitis is ruled out.
Monitoring for Intracerebral hemorrhage
Preventing secondary injury by controlling ICP.
12
Which of the following are types of Skull fractures? (SATA)
Axial
Vertebral
Linear or Depressed
Simple, Comminuted, Compound
Open or Closed
Contiguous
13
R.P. has a left cerebral epidural hematoma. The RN in the ED should find the following on assessment of R.P. :(SATA)
Headaches
Nausea & Vomiting
Right sided paraplegia and parathesias
Left pupil dilation w/ sluggish response
14
B.B. is a 78 y/o female, admitted w/ a chronic subdural hematoma. As the RN, you know: (SATA)
Chronic SDH's are common in elder and alcoholics.
Chronic SDH's have more focal s & s than s & s of increased ICP.
Occurs within 24 - 48 hours
The s & s can mimic a stroke or dementia.
Occurs within 2 to 3 days
Chronic SDH's develop over several weeks.
15
S.A. calls her HCP 10 days later c/o h/a's, difficulty concentrating, & trouble recalling things. The RN explains:
These signs are common after a concussion and can last up to 3 months.
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!
16
Which of the following are examples of diffuse traumatic brain injuries? (SATA)
Diffuse Axonal injuries
Intracerebral hemorrhages
Concussion
Basilar skull fracture
Epidural hematoma
17
As the RN, which complication(s) must you monitor for at this time? (SATA)
Cardiac dysrhythmias
Hypotension & tachycardia
Sucking head wound
Infection
18
A basilar skull fracture is a linear fracture of the base of the skull.
True
False
19
Men are twice as likely as women to sustain a traumatic brain injury.
True
False
20
The most common etiologies for traumatic brain injuries include: (SATA)
Fire arms
Falls
MVC
Sports related
21
T.R. begins to have a small amount serosanguinous dripping from his Rt nare. What is the priority intervention?
Perform a halo test
Perform a glucostix test
Instruct T.R. to blow his nose forcefully.
Insert a nasal tampon into the right nare.
22
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
Increase the risk of mortality
Increase the size of the contusion, causing it to "blossom"
Increase the severity of the injury
Decrease the size of the contusion.
23
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:
Assess for signs and symptoms of Diabetes insipidus
Assess for abnormal reflexes
Document the assessment and continue to monitor
Call the HCP STAT!
24
Diagnostics for TBI include(s): (SATA)
Coagulation panel
Cervical spine x-ray series
CT head scan w/o contrast
Toxicology screen
25
While planning the d/c teaching for your client recovering from a TBI, the RN must include the "no" policies: (SATA)
No ETOH drinking
No unsupervised smoking
No driving or use of heavy equipment
No use of firearms
26
If a client has a Glasgow Coma Score (GCS) < 10, he/she is considered to be in a comatose state.
True
False
27
The S & S of an Acute SDH are similiar to those of increased ICP.
True
False
