question

the client diagnosed with a mild concussion is being discharged from the emergency department. which discharge instruction should the nurse teach the clients significant other? 1. awake in the client every 2 hours. 2. monitor for increased intracranial pressure. 3. observe frequently for hypervigilance. 4. offer the client food every 3 to 4 hours.

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answer 1. Awakening the client every 2 hours allows the identification of headache, dizziness, lethargy, irritability, and anxiety, all signs a post concussion syndrome ,which would warrant a return to the emergency department.

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the resident in a long term care facility Fell during the previous shift and has a laceration in the occiptal area that has been closed with steri strips. Which signs or symptoms would warrant transferring the resident to the emergency department?1. A 4 centimeters area of bright red drainage on the dressing. 2. A weak pulse, shallow respirations, and cool pale skin. 3. pupils that are equal, react to light, and accommodate. 4. Complaints of a headache that's resolved with medication.

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2. These signs and symptoms indicate increased intracranial pressure from cerebral edema secondary to the fall, and they require immediate attention.

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the nurse is caring for the following clients. Which client what the nurse assess first after receiving the shift report? 1. The 22 year old male client diagnosed with a concussion who is complaining someone is waking him up every 2 hours. 2. The 36 year old female client admitted with complaints of left sided weakness who is scheduled for an MRI scan. 3. The 45-year-old client admitted with blunt trauma to the head after a motorcycle accident who has a Glasgow Coma Scale score of 6. 4. The 62-year-old client diagnosed with CVA who has expressive aphasia.

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3. The Glasgow Coma Scale is used to determine a client's response to stimuli such asEye opening response, best verbal response, and best motor response secondary to a neurological problem scores range from 3 which is a deep coma to 15 which is intact neurological function. A client with a score of 6 should be assessed first.

question

the client has sustained a severe closed head injury and the neurosurgeon is determining if the client is brain dead. Which data support That the client is brain dead?1. The clients head is turned to the right, the eyes turn to the righT. 2. the EEG has identifiable waveforms. 3. There is no Eye activity when the cold caloric test is performed. 4 the client assumes decorticate posturing when painful stimuli are applied.

answer

3. The cold caloric test, also called the ocular vestibular test, is used to determine if the brain is intact or dead. No Eye activity indicates brain death. If the client eyes moved, that would indicate that the brainstem is intact.

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the client is admitted to the medical floor with a diagnosis of closed head injury. Which nursing intervention has priority? 1. Assess nurological status. 2. Monitor pulse, respiration, and blood pressure. 3. Initiate an intravenous access. 4. Maintain an adequate airway.

answer

4. The most important nursing goal in the management of a client with a head injury is to establish and maintain adequate airway.

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question

the client diagnosed with a closed head injury is admitted to the rehabilitation department. Which medication order with the nurse question? 1. A subcutaneous anti coagulant. 2. An intravenous osmotic diuretics. 3. An oral anticonvulsant. 4. An oral proton pump inhibitor.

answer

2. An Osmotic diuretic is ordered in the acute phase to help decrease cerebral edema, but this medication would not be expected to be ordered in a rehabilitation unit.

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question

the clients diagnosed with a gunshot wound to the head assumes decorticate pOsturing when the nurse applies painful stimuli. Which assessment data obtained 3 hours later would indicate the client is improving? 1. Purposeless movement in response to painful stimuli. 2. flaccid paralysis in all four extremities. 3. Decerebrate posturing when painful stimuli are applied. 4. Pupils that are 6 millimeters in size and nonreactive to painful stimuli.

answer

1. purposeless movement indicates that the clients cerebral edema is decreasing. The best motor responses purposeful movement, but purpose less movement indicates an improvement over the Decorticate movement, which, in turn, is an improvement over decerebrate movement or flaccidity.

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question

the nurse is caring for a client diagnosed with epidural hematoma. Which nursing interventions should the nurse implement? Select all that apply. 1. Maintain the head of the bed at 60 degrees. 2. Administer stool softeners daily. 3. Ensure that pulse oximeter reading is higher than 93 percent. 4. Perform deep Nasal suction every 2 hours. 5. Administer mild sedative.

answer

correct answers 2, 3,5. Stool softeners are initiated to prevent the Bell sell the maneuver which increaseS ICP. oxygen saturation higher the 93 percent ensures oxygenation of the brain tissues. decreasing oxygen levels increase cerebral edema.mild sedative will reduce the clans agitation. Strong narcotics would not be administered because they decrease the clients loc.

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question

the client with a closed head injury has clear fluid draining from the nose. Which action should the nurse implement first? 1. Notify the health-care provider immediately. 2. Prepare to administer an antihistamine. 3. Test the drainage for presence of glucose. 4. Place 2x2 Gauze under the nose to collect drainage.

answer

3. The presence of glucose in drainage from the nose or ears indicates cerebrospinal fluid and the HCP should be notified immediately.

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question

the nurse is enjoying a day out at the lake and witnesses a water skier hit the boat ramp. The water skier is in the water not responding to verbal stimuli. The nurse is the first health care provider to respond to the accident. Which intervention should be implemented first? 1. Assess the clients loc. 2. Organize onlookers to remove the client from the lake. 3. Perform a head to toe assessment to determine injuries. 4. Stabilize the clients cervical spine.

answer

4. The nurse should always assume that the client with traumatic head injury may have sustained spinal cord injury. Moving the client could further injure the spinal cord and cause paralysis.Therefore the nurse should stabilize the cervical spinal cordas best as possible prior to removing the client from the water.

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question

the client is diagnosed with a closed head injury and is in a coma. The nurse writes the client problem as high risk for immobility complications. Which intervention would be included in the plan of care? 1. Position the client with the head of the bed elevated at intervals. 2. Performed active range of motion exercises every 4 hours. 3. Turn the client every shift and massage bony prominences. 4. Explain all procedures to the client before performing them.

answer

1. The head of the clients bed should be elevated to help the lungs expand and prevent stasis of secretions that could lead to pneumonia, a complication of immobility.

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question

the 29-year-old client that was employed as a forklift operator sustains a traumatic brain injury secondary to a motor vehicle accident. The client is being discharged from the rehabilitation unit after 3 months and has cognitive deficits. Which goal would be more realistic for this client? 1. The client will return to work within 6 months. 2. The client is able to focus and stay on task for 10 minutes. 3. The client will be able to dress self without assistance. 4. The client will regain power and bladder control.

answer

2 . Cognitive pertains to mental processes of comprehension, judgment, memory, and reasoning.

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NCLEX head injury – Flashcards

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