Deck 19: Traumatic Brain Injury

Question 1

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)Acute subdural hematoma
B)Subacute subdural hematoma
C)Epidural hematoma
D)Chronic subdural hematoma

Answer 1

Chronic subdural hematoma

Question 2

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)Symptoms of the concussion will continue for most of the patient's life.
B)The concussion might be healed; however,the patient will not recover from the symptoms.
C)Symptoms of the concussion will come and go depending on the patient's health status.
D)Symptoms of a concussion can last 3 months or more.

Answer 2

Symptoms of a concussion can last 3 months or more.

Question 3

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

A)Culture the patient's urine.
B)Contact the primary healthcare provider.
C)Administer the prn antipyretic.
D)Have the patient cough and deep breathe more frequently.

Answer 3

Administer the prn antipyretic.

Question 4

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

A)Potassium level has decreased.
B)Blood pressure has decreased.
C)Serum sodium level is increased.
D)Urine output has decreased.

Question 5

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)"We will let this patient rest between his bath and changing his linens."
B)"We are going to bathe this patient,get his linens changed,suction him,and do all of our other care early this morning,so he can get a long rest this afternoon."
C)"Be certain that we don't raise this patient's head above 10 degrees during his bath."
D)"You have to learn to suction patients with traumatic brain injury very quickly,taking no more than 30 seconds."

Question 6

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)Breathing dysfunction
B)Capacity for intracranial adaptation is decreased
C)Increased risk of paralysis
D)Increased likelihood of aspiration

Question 7

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

A)Reducing cerebral swelling
B)Confining inflammation to one area
C)Supporting absorption of debris from neuronal death
D)Limiting ischemic tissue injury

Question 8

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)"How did the injury occur?"
B)"What care was provided at the site of the injury?"
C)"Has anything like this ever happened before?"
D)Blood pressure measurement will occur.
E)A general systems assessment will occur.

Question 9

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)Electrolyte replacements
B)Maintaining adequate fluid volume
C)Supporting nutritional needs
D)Maintaining stable cerebral perfusion pressure

Question 10

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)The patient's head is supported on two pillows.
B)The head of the patient's bed is elevated to 20 degrees.
C)The patient's hips are flexed at less than 90 degrees.
D)The neck is in the patient's position of comfort,which is rotated to the left.
E)The patient is facing forward.

Question 11

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?

A)Restrict fluids.
B)Restrict sodium.
C)Monitor intravenous normal saline administration.
D)Provide potassium chloride intravenous replacements.

Question 12

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)Intracranial pressure (ICP)decreases.
B)Serum sodium is 148 mEq/L.
C)Serum osmolality is 300 mOsm.
D)Osmotic gap is 12.

Question 13

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)The patient is taking a sulfa drug for urinary tract infection.
B)The patient has a bluish discoloration behind his ear.
C)The patient's nose is running.
D)The patient's smile is crooked.
E)The patient's tongue is lacerated.

Question 14

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?

A)Maintain neutral body position.
B)Turn and reposition every 4 hours.
C)Apply antiembolism stockings.
D)Ensure oxygen saturation level of 92%.

Question 15

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

A)The accident causing this injury occurred several weeks ago.
B)There are symptoms that are similar to those demonstrated by a patient who sustained a concussion.
C)There is dilation of the pupils for several hours post injury.
D)There is presence of coma that may last for an extended period of time.

Question 16

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

A)Administer fosphenytoin (Cerebyx)4 mg per kg of patient body weight.
B)Keep the patient safe and maintain the airway.
C)Lower the head of the bed.
D)Initiate a recording of the patient's cardiac rhythm.

Question 17

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.

A)Preoxygenate the patient prior to suctioning.
B)Use very low vacuum pressure when suctioning the patient.
C)Limit suction passes to 10 to 15 seconds or less.
D)Suction when PaCO₂ levels rise above 40 mm Hg.
E)Suction the patient before and after scheduled turns.

Question 18

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)Assessing of color of the cerebral spinal fluid (CSF)
B)Assessing of the amount of cerebral spinal fluid
C)Instillation of hyperosmolar therapy via the catheter
D)Draining CSF
E)Directly monitoring the ICP

Question 19

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)Urine output has dropped from 100 mL each hour to 60 mL per hour.
B)The patient's hand grasps are weak bilaterally.
C)Fine crackles can be auscultated in the lung bases bilaterally.
D)The pupil on the side of the injury has become fixed and dilated.

Question 20

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

A)High-dose barbiturate therapy
B)High-volume intravenous fluids
C)Hyperbaric oxygen therapy
D)Hyperosmolar therapy