Traumatic Brain Injury and Increased Intracranial Pressure Practice Questions

Traumatic Brain Injury and Increased Intracranial Pressure Practice Questions 5.0 (1 review) Students also studied Terms in this set (41) Science MedicineNursing Save Increased Intracranial Pressure Quiz...13 terms sarah413162Preview ICP/head injury NCLEX style questio...50 terms Alix_VanderWiele Preview NCLEX Study questions for Chapter ...10 terms thiashia_stittsPreview Chapte 14 terms Alli The nurse assesses clear fluid coming from the nose and ears of a client admitted to the Emergency Department after a fall. The fluid is found to be cerebral spinal fluid.Based on this information, the nurse plans care for a client with which type of fracture?

• Linear
• Open
• Depressed
• Basilar
• Basilar

A client was admitted to the ICU after sustaining a closed head injury. Several hours later, the nurse assesses that the client is more lethargic and confused, is mumbling her speech, and is very difficult to arouse. The nurse takes action on this assessment for which reason?

• The client's ICP may be decreasing.
• The client is overtired from the events of the day.
• The client is oversedated.
• The client's brain injury may be worsening.
• The client's brain injury may be worsening.

A client who sustained a closed head injury has elevation of ICP. Currently the client is putting out nearly a liter of pale urine each hour. The client is diagnosed with diabetes insipidus (DI). The nurse prepares for interventions based on which pathophysiology?

• The client is retaining sodium.
• The client is producing too much growth hormone

(GH).

• The client is not producing enough antidiuretic

hormone (ADH).

• The client has too much circulating vasopressin

(DDAVP).

• The client is not producing enough antidiuretic hormone (ADH).

A client has been in the ICU for 6 weeks for treatment of a traumatic head injury. Brain death has just been declared. Which assessment findings would the nurse anticipate? Select all that apply.

• Constricted pupils
• Normal temperature
• Presence of coma
• Apnea
• Loss of brainstem reflexes
• Normal temperature
• Presence of coma
• Apnea
• Loss of brainstem reflexes

A physician order for additional mannitol (Osmitrol) has been written for a client with increased ICP. Which assessment finding would cause the nurse to question this order?

• The client is hypovolemic.
• Serum albumin is low.
• Urine myoglobin is present.
• Osmotic gap less than 10
• The client is hypovolemic.

A client sustained a closed head injury in a fall from a tree that happened 2 hours ago. There is MRI evidence of a contusion. The client has just begun to regain consciousness and has a current Glasgow Coma Scale (GCS) score of 11. The nurse should plan care for a client with which level of injury from this contusion?

• Severe
• Extreme
• Moderate
• Mild
• Moderate

A client is made hypothermic as treatment for a severe traumatic brain injury. The nurse should monitor for which complications of this therapy? Select all that apply.

• Shivering
• Decreased urine output
• Acidosis
• Atrial fibrillation
• Increased blood glucose
• Shivering
• Acidosis
• Atrial fibrillation

Which nursing action would help to optimize the client's cerebral perfusion pressure (CPP)?

• Treat fever with antipyretics as ordered.
• When turning the client, treat the body as one

continuous unit.

• Position the client in high Fowler's position.
• Keep the client's head turned to the side.
• Have the client assist with moving up in bed by pushing

with his feet.

• Treat fever with antipyretics as ordered.
• When turning the client, treat the body as one continuous unit.

A client presents to the Emergency Department with a head injury received in a fall at home. On admission, the client's Glasgow Coma Scale (GCS) score is 12. Within 20 minutes of arrival, the GCS is 8. What should the nurse do?

• Turn up the client's IV.
• Prepare the client for intubation.
• Lower the head of the bed to 30 degrees.
• Repeat the client's blood pressure reading.
• Prepare the client for intubation.

A client who sustained a head injury has been diagnosed with SIADH. Which nursing action is necessary?

• Maintain fluid restriction.
• Administer intranasal vasopressin.
• Restrict daily intake of protein.
• Administer oral salt tablets as ordered.

Maintain fluid restriction.Which information regarding postconcussion syndrome and signs to report should the nurse provide to the client who sustained a​ concussion? (Select all that​ apply.)

• Rash or hives
• Personality changes
• Sensitivity to light and noise
• Insomnia
• Nausea
• Personality changes
• Sensitivity to light and noise
• Insomnia
• Nausea

A client is seen in the urgent care center with signs of a mild traumatic brain injury​ (TBI). Which clinical manifestation would indicate a need to see a​ neurologist?

• Unequal pupils
• Raccoon eyes
• Irritability
• Tinnitus
• Unequal pupils

Which parameter should the nurse assess when administering pain medication to a client with a traumatic brain injury​ (TBI)? (Select all that​ apply.)

• Heart rate
• Pain level
• White blood cell count
• Respirations
• Bowel sounds
• Heart rate
• Pain level
• Respirations
• Bowel sounds

A client presents with an altered level of consciousness resulting from a traumatic brain injury​ (TBI). The MRI results show a large intracranial hemorrhage with a hematoma formation. Which collaborative intervention should the nurse​ anticipate?

• Antiseizure medication
• Vasoactive medication
• Surgical evacuation
• Transcranial Doppler
• Surgical evacuation

The nurse is assigning an unlicensed assistive personnel​ (UAP) to care for a client who has a traumatic brain injury​ (TBI). The nurse explains the severity of the injury. Which aspect of the plan of care can the nurse delegate to the​ UAP?

• Obtaining the signatures of the family for consent to

treat

• Administering pain medication
• Obtaining vital signs every 15-30 minutes
• Gathering assessment information for the Glasgow

Coma Scale

• Obtaining vital signs every 15-30 minutes

A nurse is caring for a patient who was recently admitted to the emergency department following a head-on motor vehicle crash. The client is unresponsive, has spontaneous respirations of 22/min, and has a laceration on the forehead that is bleeding. Which of the following is the priority nursing action at this time?

• Keep neck stabilized
• Insert nasogastric tube
• Monitor pulse and blood pressure frequently
• Establish IV access and start fluid replacement
• Keep neck stabilized