Hesi Case Study Traumatic Brain Injury – Flashcards
Unlock all answers in this set
Unlock answersquestion
assessment
answer
behind ears nasal drainage around eyes pupil equality
question
CSF
answer
Observe for a "halo" around a spot of drainage.
question
prevent increased intracranial pressure (ICP).
answer
Administer a prescribed stool softener as needed (PRN).
question
Jeff requests "something for his headache." Which medication is best for the nurse to administer to Jeff for his complaint of headache?
answer
Acetaminophen (Tylenol). This is the best choice, because Tylenol is a non-opioid analgesic, and it will not cause CNS depression.
question
What are the three components measured by the GCS?
answer
Verbal response, motor response, and eye opening. The GCS measures responses that are spontaneous and completely oriented to responses only from noxious stimuli to no response at all.
question
Jeff is medicated and reports that his headache is relieved. The nurse continues to monitor Jeff's vital signs, and his neurologic status is assessed using the Glascow Coma Scale (GCS).
answer
decreased to 10 3+3+4= 10 The GCS numerical rating ranges from 3 to 15, with 15 being the best rating, and 3 indicating a poor prognosis and high mortality rate. Any decrease of two points or more is considered significant, requiring notific
question
About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse?
answer
Diminished neurologic status.
question
What is the most important indicator of increasing ICP?
answer
Change in level of consciousness.
question
Which of these medications should not be mixed with any other medication, or any IV solution other than normal saline?
answer
Phenytoin (Dilantin).A precipitate is formed when Dilantin is mixed with other medications, so Dilantin should be administered by itself,
question
Which nursing intervention should the nurse include when administering the Mannitol?
answer
Use IV tubing with a filter. . It should be administered undiluted, but through a filter to prevent the administration of any particulates.
question
The nurse administers the normal saline using an electronic controller and a buretrol. This method of administration is chosen to reduce the risk of:
answer
This method of administration is chosen to reduce the risk of: Fluid overload.
question
The nurse prepares to administer Fuorsemide (Lasix) 20 mg IVP. The drug availability is Lasix 60 mg / 2 mL. How many mL should the nurse administer IVP? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
answer
0.7 mL
question
Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?
answer
PO2 of 95 and PCO2 of 35, The PO2 should be maintained close to, or even slightly greater than 100 to promote cerebral oxygenation. The PCO2 indicates a low normal level, which will prevent the vasodilation that occurs with hypercapnia.
question
Which documentation indicates the expected outcome of the mechanical ventilation was achieved?
answer
Client exhibits no symptoms of increased ICP.The goal of hyperventilation is to maintain cerebral oxygenation and prevent an increase in ICP by maintaining the PCO2 at a low normal level.
question
On the evening that Jeff is transferred to the Surgical Nursing Unit, he asks to see the nurse. He tells the nurse he needs to talk about something, but he will only do so if it is kept confidential.
answer
"It is possible I may have to share some of what you tell me with others."
question
What is the primary concern the supervisor should consider prior to responding to the media?
answer
Has the client authorized the release of information
question
The day after Jeff was transferred to the Surgical Unit, he becomes very irritable and requests that his drapes and door be closed, and that the lights be turned off. He tells the unlicensed assistive personnel (UAP) that he has a severe headache and wants to be left alone.
answer
Notify the health care provider of Jeff's symptoms. Jeff is exhibiting symptoms of meningitis, a serious complication requiring immediate medical and nursing intervention.
question
What additional clinical manifestation is often seen in bacterial meningitis?
answer
Rash
question
Nursing Diagnosis
answer
Risk for injury
question
RN interventions
answer
monitor educate
question
21
answer
peer identity
question
22
answer
worried about how your friends are going to react to you
question
23
answer
I may have long lasting effects from this injury
question
24
answer
have a designated driver
