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Questions and Answers
A patient is brought to the emergency department after a motor vehicle accident. The nurse notes that the patient has a clear fluid leaking from the nose. What is the priority nursing intervention?
A patient is brought to the emergency department after a motor vehicle accident. The nurse notes that the patient has a clear fluid leaking from the nose. What is the priority nursing intervention?
- Test the fluid for glucose and halo sign (correct)
- Apply direct pressure to stop the drainage
- Insert a nasogastric tube to prevent aspiration
- Administer acetaminophen for headache
Which clinical manifestation would indicate that a patient with a traumatic brain injury (TBI) is developing increased intracranial pressure (ICP)?
Which clinical manifestation would indicate that a patient with a traumatic brain injury (TBI) is developing increased intracranial pressure (ICP)?
- Tachycardia and hypotension
- Hypertension, bradycardia, and irregular respirations (correct)
- Hyperthermia and increased urine output
- Pinpoint pupils and tachypnea
A patient with a basilar skull fracture presents with bruising behind the ears and around the eyes. What nursing action is most appropriate?
A patient with a basilar skull fracture presents with bruising behind the ears and around the eyes. What nursing action is most appropriate?
- Insert a nasogastric tube for gastric decompression
- Encourage the patient to cough and deep breathe frequently
- Perform frequent neurological assessments (correct)
- Administer aspirin for pain relief
The nurse is assessing a patient who suffered a concussion. Which symptom is most concerning and warrants immediate physician notification?
The nurse is assessing a patient who suffered a concussion. Which symptom is most concerning and warrants immediate physician notification?
A patient is diagnosed with a diffuse axonal injury. The nurse knows that which statement is most accurate?
A patient is diagnosed with a diffuse axonal injury. The nurse knows that which statement is most accurate?
The nurse is caring for a patient with a traumatic brain injury. Which interventions help maintain cerebral perfusion pressure (CPP)? (Select all that apply.)
The nurse is caring for a patient with a traumatic brain injury. Which interventions help maintain cerebral perfusion pressure (CPP)? (Select all that apply.)
The nurse is teaching a group of new nurses about Cushing's triad. What signs should they monitor for? (Select all that apply.)
The nurse is teaching a group of new nurses about Cushing's triad. What signs should they monitor for? (Select all that apply.)
The nurse is monitoring a patient with a basilar skull fracture. Which findings indicate possible cerebrospinal fluid (CSF) leakage? (Select all that apply.)
The nurse is monitoring a patient with a basilar skull fracture. Which findings indicate possible cerebrospinal fluid (CSF) leakage? (Select all that apply.)
A nurse is caring for a patient with increased ICP. Which interventions should the nurse avoid? (Select all that apply.)
A nurse is caring for a patient with increased ICP. Which interventions should the nurse avoid? (Select all that apply.)
The nurse is educating a patient's family about post-concussion syndrome. Which symptoms should they monitor for? (Select all that apply.)
The nurse is educating a patient's family about post-concussion syndrome. Which symptoms should they monitor for? (Select all that apply.)
A patient with a traumatic brain injury (TBI) is exhibiting decerebrate posturing. What does this indicate?
A patient with a traumatic brain injury (TBI) is exhibiting decerebrate posturing. What does this indicate?
A patient with a closed-head injury is admitted to the ICU. The nurse notes a sudden increase in blood pressure, a widening pulse pressure, and bradycardia. What is the most appropriate nursing action?
A patient with a closed-head injury is admitted to the ICU. The nurse notes a sudden increase in blood pressure, a widening pulse pressure, and bradycardia. What is the most appropriate nursing action?
The nurse is caring for a patient with a basilar skull fracture. Which statement by the nursing student indicates the need for further teaching?
The nurse is caring for a patient with a basilar skull fracture. Which statement by the nursing student indicates the need for further teaching?
Which intervention should the nurse implement to prevent secondary brain injury in a patient with traumatic brain injury?
Which intervention should the nurse implement to prevent secondary brain injury in a patient with traumatic brain injury?
The nurse is educating a patient's family about the long-term effects of a traumatic brain injury. Which statement by the family indicates a correct understanding?
The nurse is educating a patient's family about the long-term effects of a traumatic brain injury. Which statement by the family indicates a correct understanding?
The nurse is assessing a patient with a severe TBI. Which findings suggest the need for immediate intervention? (Select all that apply.)
The nurse is assessing a patient with a severe TBI. Which findings suggest the need for immediate intervention? (Select all that apply.)
The nurse is teaching a group of new nurses about the Glasgow Coma Scale (GCS). What components are assessed? (Select all that apply.)
The nurse is teaching a group of new nurses about the Glasgow Coma Scale (GCS). What components are assessed? (Select all that apply.)
A nurse is caring for a patient with increased ICP. Which interventions help to lower ICP? (Select all that apply.)
A nurse is caring for a patient with increased ICP. Which interventions help to lower ICP? (Select all that apply.)
A patient with a mild concussion is being discharged. What instructions should the nurse provide to the caregiver? (Select all that apply.)
A patient with a mild concussion is being discharged. What instructions should the nurse provide to the caregiver? (Select all that apply.)
The nurse is preparing a patient with increased ICP for surgery. What preoperative interventions are appropriate? (Select all that apply.)
The nurse is preparing a patient with increased ICP for surgery. What preoperative interventions are appropriate? (Select all that apply.)
A patient with a traumatic brain injury is experiencing increased intracranial pressure (ICP). Which respiratory pattern should the nurse recognize as a late sign of brainstem dysfunction?
A patient with a traumatic brain injury is experiencing increased intracranial pressure (ICP). Which respiratory pattern should the nurse recognize as a late sign of brainstem dysfunction?
A patient with a closed-head injury exhibits new-onset restlessness and agitation. What should the nurse do first?
A patient with a closed-head injury exhibits new-onset restlessness and agitation. What should the nurse do first?
A nurse is assessing a patient with a basilar skull fracture. Which finding is most concerning?
A nurse is assessing a patient with a basilar skull fracture. Which finding is most concerning?
A patient with a severe traumatic brain injury (TBI) is receiving mannitol. Which finding would indicate that the medication is effective?
A patient with a severe traumatic brain injury (TBI) is receiving mannitol. Which finding would indicate that the medication is effective?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 6. What does this indicate?
A patient with a head injury has a Glasgow Coma Scale (GCS) score of 6. What does this indicate?
The nurse is monitoring a patient with a traumatic brain injury. Which early signs of increased ICP should the nurse assess for? (Select all that apply.)
The nurse is monitoring a patient with a traumatic brain injury. Which early signs of increased ICP should the nurse assess for? (Select all that apply.)
A patient with a TBI is experiencing Cushing's triad. What interventions should the nurse anticipate? (Select all that apply.)
A patient with a TBI is experiencing Cushing's triad. What interventions should the nurse anticipate? (Select all that apply.)
The nurse is preparing discharge instructions for a patient with a mild concussion. What should be included? (Select all that apply.)
The nurse is preparing discharge instructions for a patient with a mild concussion. What should be included? (Select all that apply.)
The nurse is teaching about diffuse axonal injury (DAI). What statements indicate correct understanding? (Select all that apply.)
The nurse is teaching about diffuse axonal injury (DAI). What statements indicate correct understanding? (Select all that apply.)
A patient with a traumatic brain injury is experiencing post-traumatic seizures. What interventions should the nurse implement? (Select all that apply.)
A patient with a traumatic brain injury is experiencing post-traumatic seizures. What interventions should the nurse implement? (Select all that apply.)
What is the most important factor in preventing secondary brain injury?
What is the most important factor in preventing secondary brain injury?
Which patient is at highest risk for chronic traumatic encephalopathy (CTE)?
Which patient is at highest risk for chronic traumatic encephalopathy (CTE)?
The nurse is caring for a patient with a mild TBI. Which assessment finding requires immediate intervention?
The nurse is caring for a patient with a mild TBI. Which assessment finding requires immediate intervention?
The nurse is evaluating a patient with a GCS score of 3. What is the expected clinical presentation?
The nurse is evaluating a patient with a GCS score of 3. What is the expected clinical presentation?
Flashcards
CSF Leakage Indication
CSF Leakage Indication
Fluid leaking from the nose after head trauma may indicate cerebrospinal fluid leakage. Testing for glucose or the 'halo sign' helps confirm CSF presence.
Cushing's Triad
Cushing's Triad
Hypertension, bradycardia, and irregular respirations, indicates brainstem herniation.
Basilar Skull Fracture Signs
Basilar Skull Fracture Signs
Bruising behind the ears (Battle's sign) and around the eyes (raccoon eyes) indicate a basilar skull fracture. Frequent neuro assessments help detect worsening symptoms.
Concerning Concussion Symptoms
Concerning Concussion Symptoms
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Diffuse Axonal Injury (DAI)
Diffuse Axonal Injury (DAI)
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Maintain Cerebral Perfusion Pressure
Maintain Cerebral Perfusion Pressure
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Cushing's Triad Components
Cushing's Triad Components
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Interventions to Avoid with Increased ICP
Interventions to Avoid with Increased ICP
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Post-Concussion Syndrome Symptoms
Post-Concussion Syndrome Symptoms
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Decerebrate Posturing
Decerebrate Posturing
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Sudden BP Increase and Bradycardia Cause
Sudden BP Increase and Bradycardia Cause
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Basilar Fracture NG Tube Risk
Basilar Fracture NG Tube Risk
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Prevent Secondary Brain Injury
Prevent Secondary Brain Injury
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Long-Term TBI Effects
Long-Term TBI Effects
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GCS score of 3:
GCS score of 3:
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Study Notes
- Post-motor vehicle accident, clear nasal fluid indicates possible cerebrospinal fluid (CSF) leakage.
- Test the fluid leaking from the nose for glucose or perform a "halo sign" test to confirm the presence of CSF.
- Hypertension, bradycardia, and irregular respirations indicate increased intracranial pressure (ICP) and brainstem herniation.
Basilar Skull Fracture
- Bruising behind the ears (Battle's sign) and around the eyes (raccoon eyes/periorbital ecchymosis) suggest a basilar skull fracture.
- Slurred speech and unilateral pupil dilation after sustaining a concussion, are indicators of deteriorating neurological function and potential increase in ICP.
- Diffuse axonal injury (DAI) involves widespread white matter shearing due to traumatic forces, leading to long-term disability.
Cerebral Perfusion Pressure (CPP)
- Interventions to maintain CPP are: elevating the head of the bed, maintaining a neutral head and neck position, administering IV fluids, and monitoring for Cushing's triad.
- Frequent coughing increases ICP and should be avoided.
Cushing's Triad
- Cushing's triad consists of hypertension (widened pulse pressure), bradycardia, and irregular respirations, it is a late sign of increased ICP.
- Findings that indicate possible cerebrospinal fluid (CSF) leakage are: clear fluid from the nose or ears, positive halo sign, and positive glucose test in fluid drainage.
Increased ICP
- Interventions to avoid in a patient with increased ICP: frequent suctioning and keeping the head of the bed flat.
- Post-concussion syndrome includes memory problems, difficulty concentrating, fatigue, and irritability.
- Decerebrate posturing (rigid extension of extremities) indicates damage at the midbrain or brainstem level.
- Symptoms indicate Cushing's triad, a late sign of increased intracranial pressure (ICP), and immediate intervention is required to prevent herniation.
- A nasogastric (NG) tube should not be inserted in a patient with a basilar skull fracture due to the risk of the tube passing into the brain through the skull fracture.
- Hypoxia can lead to secondary injury by increasing cerebral edema and ischemia, so oxygenation should be optimized.
- Traumatic brain injuries (TBIs) can result in long-term cognitive, memory, and personality changes
- Findings that suggest immediate intervention for severe TBI are: fixed/dilated pupils, irregular respirations, projectile vomiting, and increased agitation indicating rising intracranial pressure and impending brain herniation.
- The Glasgow Coma Scale (GCS) assesses eye opening, motor response, and verbal response.
- For increased ICP interventions helping to lower ICP include elevating the HOB, reducing stimulation, and administering mannitol, as prescribed
Mild Cuncussion
- With a mild concussion neuro checks should be performed, acetaminophen can be administered for pain and to monitor for worsening symptoms.
- Head elevation, stool softeners, and osmotic diuretics like mannitol help manage ICP.
- Cheyne-Stokes respirations, characterized by irregular breathing with periods of apnea, indicate brainstem dysfunction and worsening ICP.
- Agitation or restlessness may indicate increasing ICP and requires a prompt neurological assessment.
- A decreasing level of consciousness suggests worsening neurological status and possible herniation.
- Mannitol reduces cerebral edema and ICP, which leads to an improved level of consciousness.
- A GCS score of 3-8 indicates severe brain injury, moderate TBI is 9-12, and mild TBI is 13-15.
Increased ICP
- Early signs of increased ICP include headache, restlessness, and nausea/vomiting; widened pulse pressure and pupillary changes are late signs.
- Early interventions for a patient with TBI experiencing Cushing's triad are administering mannitol, elevating the head of the bed, and preparing for emergency surgery.
- Patients should avoid CNS depressants, to monitor for vomiting (worsening symptoms) and difficulty arousing.
- Diffuse axonal injury (DAI) is caused by shearing forces, leads to long-term disability, and often results in coma despite minimal imaging findings.
- Antiepileptics should be administered to prevent seizures, provide a padded environment, monitor for postictal confusion, but avoid supine positioning and inserting an airway during seizures.
- Preventing hypoxia and hypotension is critical to avoid further secondary brain damage.
- Chronic traumatic encephalopathy (CTE) is caused by repeated head trauma and is most often seen in boxers and football players.
- Repeated vomiting requires further evaluation and may indicate increasing ICP.
- A GCS of 3 indicates no response in all three categories, suggesting deep coma or brain death.
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