Podcast
Questions and Answers
Which of the following is a type of primary traumatic brain injury (TBI)?
Which of the following is a type of primary traumatic brain injury (TBI)?
- Infection
- Concussion (correct)
- Cerebral edema
- Hypoxia
What does the Glasgow Coma Scale assess?
What does the Glasgow Coma Scale assess?
- Consciousness level (correct)
- Sensory loss
- Intracranial pressure
- Memory function
What type of skull fracture involves multiple bone fragments?
What type of skull fracture involves multiple bone fragments?
- Depressed
- Comminuted (correct)
- Basilar
- Linear
Which area is pierced in a brain laceration?
Which area is pierced in a brain laceration?
Which of the following is considered a non-penetrating injury?
Which of the following is considered a non-penetrating injury?
A patient with a TBI has bradycardia, irregular respirations, and hypertension. What condition does this indicate?
A patient with a TBI has bradycardia, irregular respirations, and hypertension. What condition does this indicate?
Why is maintaining cerebral perfusion pressure (CPP) important in TBI management?
Why is maintaining cerebral perfusion pressure (CPP) important in TBI management?
What is the most common mechanism of injury leading to diffuse axonal injury (DAI)?
What is the most common mechanism of injury leading to diffuse axonal injury (DAI)?
The nurse notices a patient post-head trauma becoming increasingly lethargic. What is the best initial action?
The nurse notices a patient post-head trauma becoming increasingly lethargic. What is the best initial action?
A patient presents with clear fluid leaking from the nose post-trauma. What should the nurse suspect?
A patient presents with clear fluid leaking from the nose post-trauma. What should the nurse suspect?
Which nursing intervention helps reduce increased ICP in a TBI patient?
Which nursing intervention helps reduce increased ICP in a TBI patient?
Which of the following cues best indicate deterioration in a TBI patient?
Which of the following cues best indicate deterioration in a TBI patient?
Which combination of findings supports the diagnosis of a primary TBI? (SATA)
Which combination of findings supports the diagnosis of a primary TBI? (SATA)
A patient is scoring 7 on the Glasgow Coma Scale. Which of the following findings are consistent with this score?
A patient is scoring 7 on the Glasgow Coma Scale. Which of the following findings are consistent with this score?
A nurse is evaluating the effectiveness of mannitol in a TBI patient. Which finding indicates it is working?
A nurse is evaluating the effectiveness of mannitol in a TBI patient. Which finding indicates it is working?
After suctioning a TBI patient, the nurse notices a sudden drop in GCS. What is the best next action?
After suctioning a TBI patient, the nurse notices a sudden drop in GCS. What is the best next action?
Which multidisciplinary team members are appropriate for long-term TBI recovery? (SATA)
Which multidisciplinary team members are appropriate for long-term TBI recovery? (SATA)
The nurse is planning care for a patient with TBI. Which of the following outcomes are appropriate? (SATA)
The nurse is planning care for a patient with TBI. Which of the following outcomes are appropriate? (SATA)
Which of the following is the leading cause of long-term disability in TBI?
Which of the following is the leading cause of long-term disability in TBI?
What is the purpose of the Glasgow Coma Scale motor component?
What is the purpose of the Glasgow Coma Scale motor component?
What symptom is most associated with a basilar skull fracture?
What symptom is most associated with a basilar skull fracture?
Why is rapid acceleration a concern in TBI?
Why is rapid acceleration a concern in TBI?
The nurse observes a patient with posturing following a TBI. Which action is the priority?
The nurse observes a patient with posturing following a TBI. Which action is the priority?
A patient with a TBI needs to be transported for a CT scan. What is the nurse's top priority during transport?
A patient with a TBI needs to be transported for a CT scan. What is the nurse's top priority during transport?
Which assessment findings in a TBI patient suggest increasing intracranial pressure? (SATA)
Which assessment findings in a TBI patient suggest increasing intracranial pressure? (SATA)
A patient scores “1” on eye opening in the GCS. What does this mean?
A patient scores “1” on eye opening in the GCS. What does this mean?
The nurse suspects secondary TBI in a patient. Which findings support this? (SATA)
The nurse suspects secondary TBI in a patient. Which findings support this? (SATA)
After administering hypertonic saline, what indicates a positive response in a TBI patient?
After administering hypertonic saline, what indicates a positive response in a TBI patient?
Which of the following interventions should be evaluated for effectiveness in promoting airway clearance in TBI patients? (SATA)
Which of the following interventions should be evaluated for effectiveness in promoting airway clearance in TBI patients? (SATA)
Which findings require immediate evaluation after head trauma? (SATA)
Which findings require immediate evaluation after head trauma? (SATA)
The nurse is designing a care plan for a TBI patient. What is the most important goal?
The nurse is designing a care plan for a TBI patient. What is the most important goal?
What are appropriate long-term nursing goals for a TBI patient undergoing rehab? (SATA)
What are appropriate long-term nursing goals for a TBI patient undergoing rehab? (SATA)
A TBI patient is being discharged. Which teaching points should the nurse include? (SATA)
A TBI patient is being discharged. Which teaching points should the nurse include? (SATA)
Which strategies should be included in a plan to prevent secondary injury in TВІ? (SATA)
Which strategies should be included in a plan to prevent secondary injury in TВІ? (SATA)
What is the nurse's priority when caring for a TBI patient at risk for aspiration?
What is the nurse's priority when caring for a TBI patient at risk for aspiration?
During rehabilitation, which team member helps with daily living skills for a TВІ patient?
During rehabilitation, which team member helps with daily living skills for a TВІ patient?
What is the most appropriate nursing diagnosis for a TBI patient with altered LOC?
What is the most appropriate nursing diagnosis for a TBI patient with altered LOC?
Which signs indicate that a TBI patient may need intubation? (SATA)
Which signs indicate that a TBI patient may need intubation? (SATA)
A patient with a concussion asks when they can resume sports. What is the best response?
A patient with a concussion asks when they can resume sports. What is the best response?
A nurse observes a TBI patient becoming restless and pulling at lines. What is the most appropriate intervention?
A nurse observes a TBI patient becoming restless and pulling at lines. What is the most appropriate intervention?
Flashcards
Concussion
Concussion
A functional injury resulting from trauma, classified as a primary TBI.
Glasgow Coma Scale
Glasgow Coma Scale
Evaluates the level of consciousness in TBI patients.
Comminuted Fracture
Comminuted Fracture
A fracture with multiple bone fragments.
Brain Laceration
Brain Laceration
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Non-penetrating Injury
Non-penetrating Injury
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Cushing's Triad
Cushing's Triad
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Importance of CPP in TBI
Importance of CPP in TBI
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Diffuse Axonal Injury (DAI)
Diffuse Axonal Injury (DAI)
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Lethargic Post-Head Trauma
Lethargic Post-Head Trauma
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Leading Cause of Long-Term Disability in TBI
Leading Cause of Long-Term Disability in TBI
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Study Notes
- Concussion is a functional injury from trauma that is classified as a primary TBI
- Edema, hypoxia, and infection are secondary complications of TBIs
- The Glasgow Coma Scale assesses the level of consciousness in TBI patients
- A comminuted fracture is a break with multiple fragments
- Brain lacerations involve tears through the pia and arachnoid membranes
- Blunt trauma causes closed head injuries, which are non-penetrating
Cushing's Triad
- Cushing's Triad (bradycardia, irregular respirations, and hypertension) indicates increased intracranial pressure
Cerebral Perfusion Pressure
- Maintaining adequate cerebral perfusion pressure (CPP) ensures oxygen and nutrient delivery to the brain
Diffuse Axonal Injury (DAI)
- Rapid acceleration or deceleration causes shearing in DAI
Initial action for lethargic patient post-head trauma
- Reassess Glasgow Coma Scale when a patient post-head trauma becomes increasingly lethargic
Clear fluid leaking from the nose post-trauma
- Suspect a skull base fracture if there is clear fluid leaking from nose post-trauma
Nursing intervention to reduce ICP in a TBI patient
- Elevate head of bed to 30° to promote venous drainage and lower ICP
Deterioration in a TBI patient
- Agitation and irritability could be an early sign of increased ICP or neurological decline
Primary TBIs
- Diffuse axonal injury, basilar skull fracture, laceration, and hemorrhage
Glasgow Coma Scale (GCS) Score of 7
- Extension to pain indicates severe brain injury
Effectiveness of Mannitol
- Improved level of consciousness indicates that mannitol is effectively reducing ICP
Sudden drop in GCS after suctioning a TBI patient
- Notify the provider
Multidisciplinary team members for long-term TBI recovery
- Speech-language pathologist, occupational therapist, and cognitive rehabilitation specialist are essential
Appropriate outcomes for TBI patient care
- Maintain patent airway, express feelings appropriately, improve GCS score, and avoid secondary injury
Leading cause of long-term disability in TBIs
- Diffuse axonal injury (DAI) often results in severe, long-term impairment due to widespread axonal damage
Glasgow Coma Scale motor component
- Assesses the patient's response to painful or verbal stimuli
Basilar skull fracture
- CSF otorrhea (drainage from the ear) is a hallmark sign
Rapid acceleration
- It is a concern in TBI due to causing diffuse axonal injury
Priority action for patient posturing following a TBI
- Notify the healthcare provider as posturing indicates possible increased ICP or brainstem damage
Priority during transport of TBI patient to CT scan
- Maintain cervical spine precautions until spinal injuries are ruled out
Assessment findings suggesting increasing intracranial pressure in TBI patient
- Pupil dilation on one side, bradycardia, projectile vomiting, and confusion are classic signs
Glasgow Coma Scale eye opening score of 1
- No eye opening
Findings supporting secondary TBI
- Hypoxia, seizures, cerebral edema
Indication of positive response to administering hypertonic saline
- Improved level of consciousness as hypertonic saline reduces ICP
Interventions to evaluate for promoting airway clearance in TBI patients
- Suctioning, chest physiotherapy, deep breathing exercises, and monitoring ABGs
Findings requiring immediate evaluation after head trauma
- Battle's sign, periorbital ecchymosis and increasing drowsiness may indicate a skull fracture or increased ICP
Most important goal when designing a care plan for a TBI patient
- Maintain cerebral perfusion
Appropriate long-term nursing goals for a TBI patient undergoing rehab
- Participate in therapy sessions, express emotions appropriately, maintain airway patency, and achieve optimal mobility
Discharge teaching points for TBI patient
- Avoid contact sports, monitor for sleep changes, report any confusion, and take all medications as prescribed
Strategies to prevent secondary injury in TBI
- Maintain oxygenation, ensure normothermia, control blood glucose, and monitor ICP
Nurse's priority when caring for a TBI patient at risk for aspiration
- Elevate head of bed to reduce aspiration risk
Team member helps with daily living skills for a TBI patient during rehabilitation
- Occupational therapist helps patients adapt to daily living activities
Most appropriate nursing diagnosis for a TBI patient with altered LOC
- Ineffective airway clearance as altered LOC impairs protective airway reflexes
Signs indicating intubation for a TBI patient
- GCS ≤ 8, snoring respirations, and unresponsive to verbal stimuli suggest compromised airway or LOC
Advice for patient with a concussion asking about resuming sports
- Resuming sports should only happen after full symptom resolution and clearance to prevent second impact syndrome
Most appropriate intervention for restless TBI patient pulling at lines
- Reorient the patient and monitor as first-line action includes non-pharmacological interventions unless behavior worsens
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