Exam 19: Traumatic Brain Injury

The nurse is caring for a patient recovering from surgery to evacuate an epidural hematoma.Which assessment finding would warrant immediate collaboration with the surgeon?

A patient comes into the emergency department with complaints of headache,lethargy,and vomiting.He reports being hit in the head by a batted baseball during a company picnic "about 6 weeks ago." The nurse would ask additional assessment questions regarding which condition?

A patient with traumatic brain injury has had placement of an intraventricular catheter (IVC).The nurse participates in tier two interventions to reduce intracranial pressure (ICP)through which uses of this catheter? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient is brought to the hospital after being found on the floor at the bottom of a flight of stairs.The patient has an obvious depressed skull fracture and is bleeding from her right ear.Initially,the nurse assesses the patency of the patient's airway,her breathing,and the rate and rhythm of her pulse.What assessments and questions will be part of the nurse's secondary survey? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F.What is the priority nursing intervention?

A patient being treated for increased intracranial pressure (ICP)from a traumatic brain injury demonstrates an increase in pressure with minimal care activity.What instruction should the nurse provide the nursing student assisting with care for this patient?

A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure (ICP).The patient is confused and occasionally combative.His wife expresses concern about how to tell their two young sons.Which priority patient problem is most likely present in this patient and will guide initial selection of nursing interventions?

A patient with traumatic brain injury continues to have increased intracranial pressure despite conventional therapeutic interventions.The nurse would anticipate which tier three intervention?

The admission orders for a patient with traumatic brain injury say to keep the patient's head elevated with neutral body positioning.Which patient positioning would the nurse consider as meeting this requirement? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient diagnosed with a traumatic brain injury is receiving mannitol.The nurse would collaborate with the prescriber regarding discontinuation of therapy if which finding occurs?

A patient with a traumatic brain injury is being treated for diabetes insipidus.Which finding would the nurse evaluate as indicating treatment is effective?

The family of a patient with a concussion is concerned that the patient continues to complain of and demonstrate ongoing neurological deficits even though the injury occurred 6 weeks ago.What information should the nurse provide?

A patient is admitted with a traumatic brain injury (TBI).The nurse would anticipate participating in interventions toward which immediate goal?

A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting.Which interventions would the nurse include in this patient's plan of care?

is admitted to the emergency department after sustaining injury in a fall.Which assessment findings would the nurse immediately communicate to the emergency department physician? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.

A patient being treated for a traumatic brain injury for 3 days begins to seize.Which intervention is the nurse's priority?

A patient with a moderate diffuse head injury is demonstrating a variety of neurological symptoms.What is the priority when caring for this patient?

A patient diagnosed with mild diffuse axonal injury is being admitted to the intensive care unit.The nurse would anticipate which assessment findings?

A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility.Which nursing intervention is indicated?

The patient with traumatic brain injury has been intubated and placed on mechanical ventilation.Which nursing interventions would help optimize oxygenation? Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply.