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Questions and Answers
A patient arrives at the emergency department after a motor vehicle accident. The nurse notes Battle's sign and clear drainage from the ear. Which type of skull fracture should the nurse suspect?
A patient arrives at the emergency department after a motor vehicle accident. The nurse notes Battle's sign and clear drainage from the ear. Which type of skull fracture should the nurse suspect?
- Comminuted
- Linear
- Depressed
- Basilar (correct)
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 6. What is the priority nursing action?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 6. What is the priority nursing action?
- Administer pain medication
- Maintain spinal immobilization
- Prepare for intubation (correct)
- Perform a neurological assessment
A patient with a traumatic brain injury (TBI) presents with widened pulse pressure, bradycardia, and irregular respirations. What does the nurse suspect?
A patient with a traumatic brain injury (TBI) presents with widened pulse pressure, bradycardia, and irregular respirations. What does the nurse suspect?
- Brainstem herniation
- Neurogenic shock
- Autonomic dysreflexia
- Cushing's triad (correct)
The nurse is repositioning a patient with a TBI. Which intervention will help prevent an increase in ICP?
The nurse is repositioning a patient with a TBI. Which intervention will help prevent an increase in ICP?
A patient with a concussion is discharged home. Which statement by the caregiver indicates a need for further teaching?
A patient with a concussion is discharged home. Which statement by the caregiver indicates a need for further teaching?
A patient with a moderate TBI has an ICP monitor placed. Which ICP reading requires immediate intervention?
A patient with a moderate TBI has an ICP monitor placed. Which ICP reading requires immediate intervention?
A patient with a severe TBI develops diabetes insipidus (DI). Which assessment finding is consistent with this condition?
A patient with a severe TBI develops diabetes insipidus (DI). Which assessment finding is consistent with this condition?
A patient with a TBI has a Glasgow Coma Scale (GCS) score of 10. How should the nurse classify the severity of the injury?
A patient with a TBI has a Glasgow Coma Scale (GCS) score of 10. How should the nurse classify the severity of the injury?
The nurse is caring for a patient with a basilar skull fracture. Which action is most appropriate?
The nurse is caring for a patient with a basilar skull fracture. Which action is most appropriate?
A patient with a severe TBI is placed on mechanical ventilation. Which parameter should the nurse monitor to prevent secondary brain injury?
A patient with a severe TBI is placed on mechanical ventilation. Which parameter should the nurse monitor to prevent secondary brain injury?
Which intervention is most effective in reducing ICP in a patient with a TBI?
Which intervention is most effective in reducing ICP in a patient with a TBI?
The nurse is assessing a patient with a TBI. Which finding suggests brainstem involvement?
The nurse is assessing a patient with a TBI. Which finding suggests brainstem involvement?
A patient with a TBI is receiving mannitol. Which finding indicates the medication is effective?
A patient with a TBI is receiving mannitol. Which finding indicates the medication is effective?
The nurse is teaching the family of a patient with a mild concussion about discharge instructions. Which statement requires further teaching?
The nurse is teaching the family of a patient with a mild concussion about discharge instructions. Which statement requires further teaching?
The nurse is caring for a patient with a TBI who has increased ICP. Which intervention should be avoided?
The nurse is caring for a patient with a TBI who has increased ICP. Which intervention should be avoided?
The nurse is monitoring a patient with a closed head injury. Which finding indicates worsening neurological status?
The nurse is monitoring a patient with a closed head injury. Which finding indicates worsening neurological status?
A patient with a TBI is on a ventilator. The provider orders to maintain PaCO2 between 30-35 mmHg. What is the purpose of this intervention?
A patient with a TBI is on a ventilator. The provider orders to maintain PaCO2 between 30-35 mmHg. What is the purpose of this intervention?
The nurse is caring for a patient with a severe TBI. Which assessment finding indicates brainstem dysfunction?
The nurse is caring for a patient with a severe TBI. Which assessment finding indicates brainstem dysfunction?
A patient with a TBI suddenly develops projectile vomiting without nausea. What should the nurse suspect?
A patient with a TBI suddenly develops projectile vomiting without nausea. What should the nurse suspect?
Which assessment finding is most concerning in a patient with a concussion?
Which assessment finding is most concerning in a patient with a concussion?
A patient with a TBI is receiving phenytoin for seizure prevention. Which lab value requires immediate intervention?
A patient with a TBI is receiving phenytoin for seizure prevention. Which lab value requires immediate intervention?
The nurse is monitoring a patient with a basilar skull fracture. Which sign suggests a cerebrospinal fluid (CSF) leak?
The nurse is monitoring a patient with a basilar skull fracture. Which sign suggests a cerebrospinal fluid (CSF) leak?
Which assessment finding in a patient with increased ICP indicates that brain herniation is imminent?
Which assessment finding in a patient with increased ICP indicates that brain herniation is imminent?
A patient with a moderate TBI is placed on seizure precautions. Which action should the nurse take?
A patient with a moderate TBI is placed on seizure precautions. Which action should the nurse take?
The nurse is teaching a patient with a mild concussion about returning to activity. Which statement indicates a need for further teaching?
The nurse is teaching a patient with a mild concussion about returning to activity. Which statement indicates a need for further teaching?
The nurse is preparing a patient with a TBI for a CT scan. Which action is most important?
The nurse is preparing a patient with a TBI for a CT scan. Which action is most important?
The nurse is reviewing discharge instructions for a patient with a mild TBI. Which statement requires correction?
The nurse is reviewing discharge instructions for a patient with a mild TBI. Which statement requires correction?
The nurse is assessing a patient with increased ICP. Which findings are expected? (Select all that apply.)
The nurse is assessing a patient with increased ICP. Which findings are expected? (Select all that apply.)
A patient with a TBI is at risk for seizures. What precautions should the nurse implement? (Select all that apply.)
A patient with a TBI is at risk for seizures. What precautions should the nurse implement? (Select all that apply.)
Which interventions help prevent secondary brain injury in a TBI patient? (Select all that apply.)
Which interventions help prevent secondary brain injury in a TBI patient? (Select all that apply.)
The nurse is caring for a patient with diffuse axonal injury. Which clinical manifestations are expected? (Select all that apply.)
The nurse is caring for a patient with diffuse axonal injury. Which clinical manifestations are expected? (Select all that apply.)
A patient with a severe TBI is at risk for brain herniation. Which signs indicate impending herniation? (Select all that apply.)
A patient with a severe TBI is at risk for brain herniation. Which signs indicate impending herniation? (Select all that apply.)
The nurse is monitoring a patient for signs of increased ICP. Which findings are concerning? (Select all that apply.)
The nurse is monitoring a patient for signs of increased ICP. Which findings are concerning? (Select all that apply.)
The nurse is caring for a patient with a TBI. Which interventions help prevent secondary brain injury? (Select all that apply.)
The nurse is caring for a patient with a TBI. Which interventions help prevent secondary brain injury? (Select all that apply.)
A patient with a TBI has Cushing's triad. What signs are expected? (Select all that apply.)
A patient with a TBI has Cushing's triad. What signs are expected? (Select all that apply.)
Flashcards
Basilar Skull Fracture Signs
Basilar Skull Fracture Signs
Bruising behind the ear and clear ear drainage, indicating a break at the skull's base.
Cushing's Triad
Cushing's Triad
Hypertension, bradycardia, and irregular respirations, indicating increased intracranial pressure and brainstem herniation.
HOB Elevation for ICP
HOB Elevation for ICP
Elevating the head of the bed promotes venous drainage, reducing ICP and cerebral edema.
Diabetes Insipidus in TBI
Diabetes Insipidus in TBI
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Decerebrate Posturing
Decerebrate Posturing
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Mannitol Effectiveness
Mannitol Effectiveness
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Why avoid ibuprofen in TBI?
Why avoid ibuprofen in TBI?
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CSF Leak Detection
CSF Leak Detection
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Seizure Precautions
Seizure Precautions
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PaCO2 target with ventilator
PaCO2 target with ventilator
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Early Signs of Increased ICP
Early Signs of Increased ICP
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ICP reading needing intervention
ICP reading needing intervention
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GCS score and intubation
GCS score and intubation
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Fixed, dilated pupils.
Fixed, dilated pupils.
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Projectile vomiting
Projectile vomiting
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Study Notes
Basilar Skull Fracture
- Battle's sign (bruising behind the ear) and clear drainage from the ear (CSF leakage) are indicators.
- This fracture involves the base of the skull.
- It can lead to dural tears and increases the risk of meningitis.
- You should monitor for signs of meningitis.
- NG tube and nasal suctioning are contraindicated due to the risk of intracranial placement.
- CSF leaks from the nose (rhinorrhea) or ears (otorrhea) test positive for glucose, unlike mucus.
Glasgow Coma Scale (GCS)
- A GCS of 6 indicates severe brain injury and an inability to protect the airway.
- Intubation is necessary to prevent hypoxia and aspiration in a patient with a GCS score of 6.
- A GCS score of 9-12 indicates moderate TBI.
- Mild TBI = 13-15, Severe TBI = ≤ 8.
Cushing's Triad
- Cushing's triad (hypertension with widened pulse pressure, bradycardia, and irregular respirations) is a late sign of increased intracranial pressure (ICP).
- It indicates impending brainstem herniation.
Interventions for TBI
- Elevating the head of the bed to 30 degrees promotes venous drainage, reducing ICP.
- Lying flat can increase cerebral edema.
- Maintaining oxygen saturation >90% is crucial to prevent secondary brain injury.
- A neutral neck position promotes venous drainage and prevents ICP elevation.
- Coughing, suctioning, and Trendelenburg positioning can increase ICP.
Medications for TBI
- NSAIDs like ibuprofen increase the risk of bleeding.
- Acetaminophen (Tylenol) is a safer option.
- Mannitol is an osmotic diuretic used to reduce cerebral edema.
- Increased urine output and stable neurological status indicate effectiveness of mannitol.
- Phenytoin's therapeutic range is 10-20 mcg/mL.
- A level of 5 mcg/mL is subtherapeutic, increasing seizure risk.
- Meperidine is avoided due to its seizure risk.
- Aspirin is avoided due to its risk of bleeding, acetaminophen is preferred for pain.
Intracranial Pressure (ICP)
- Normal ICP is 5-15 mmHg.
- An ICP of >20 mmHg indicates increased intracranial pressure, requiring immediate intervention to prevent brain herniation.
- Early signs of increased ICP include restlessness, slurred speech, drowsiness, and sudden vomiting due to pressure changes in the brain.
- Increased ICP can cause Cushing's triad (hypertension, bradycardia, and irregular respirations), pupil changes, and altered consciousness.
- Lowering PaCO2 to 30-35 mmHg induces mild cerebral vasoconstriction, reducing cerebral blood flow and ICP.
- Excessive reduction of PaCO2 can lead to ischemia.
- Interventions to prevent secondary brain injury: preventing hypoxia, controlling ICP, elevating the HOB, and using hypertonic saline.
Concussion
- Patients with a concussion should be woken up every few hours to assess for signs of neurological deterioration.
- Repeated vomiting is a red flag for worsening brain injury and requires immediate evaluation for increased ICP.
Seizures
- Seizure precautions include padded side rails, suction readiness, and anticonvulsant therapy.
- Tongue blades are contraindicated due to aspiration risk.
- For a patient with a moderate TBI on seizure precautions, keep padded side rails up.
Diabetes Insipidus (DI)
- DI results from injury to the hypothalamus or pituitary, causing ADH deficiency.
- It leads to polyuria, dilute urine, dehydration, and hypernatremia.
Brainstem Dysfunction
- Decerebrate posturing (arms extended, wrists pronated) is a sign of severe brainstem dysfunction, indicating poor prognosis.
- Brain herniation presents with fixed pupils, abnormal posturing, irregular respirations, and sudden neurological deterioration.
Diffuse Axonal Injury (DAI)
- Diffuse axonal injury (DAI) is a severe TBI causing immediate unconsciousness, posturing, and possible persistent vegetative state due to widespread brain damage.
Brain Herniation
- Projectile vomiting without nausea is a classic sign of increased ICP, which may indicate brain herniation.
- Fixed, dilated pupils ("blown pupils") indicate brainstem compression and impending herniation, requiring emergency intervention.
CT Scan
- For contrast-enhanced CT scans, allergy assessment (iodine/shellfish) is crucial to prevent anaphylaxis.
Worsening Neurological Status
- Widening pulse pressure (increasing systolic with stable/low diastolic pressure) is a sign of Cushing's triad, indicating rising ICP and impending herniation.
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