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The Client with Head Injury

1. An unconscious client with multiple injuries arrives in the emergency room. Which nursing intervention receives the highest priority? 1. Establishing an airway. 2. Replacing blood loss. 3. Stopping bleeding from open wounds. 4. Checking for a neck fracture. The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other care measures will be futile. Replacing blood loss, stopping bleeding from open wounds, and checking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established. 2. A client is at risk for increased intracranial pressure (ICP). Which of the following would be the priority for the nurse to monitor? 1. Unequal pupil size. 2. Decreasing systolic blood pressure 3. Tachycardia. 4. Decreasing body temperature. Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve. Increasing ICP causes an increase in the systolic pressure, which reflects the additional pressure needed to perfuse the brain. It increases the pressure on the vagus nerve, which produces bradycardia, and it causes an increase in body temperature from hypothalamic damage. 3. What should the nurse do first when a client with a head injury begins to have clear drainage from his nose? 1. Compress the nares. 2. Tilt the head back. 3. Give the client a white pad to collect the fluid. 4. Administer an antihistamine for postnasal drip. The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse would not place tissues at the bedside because it is important to know how much leakage of CSF is occurring. Compressing the nares will obstruct the drainage flow. It is inappropriate to tilt the head back, which would allow the fluid to drain down the throat and not be collected for a sample. It is inappropriate to administer an antihistamine because the drainage may not be from postnasal drip. 4. Which of the following respiratory patterns indicate increasing ICP in the brain stem? 1. Slow, irregular respirations. 2. Rapid, shallow respirations. 3. Asymmetric chest excursion. 4. Nasal flaring.

Rapid. mucus does not. Decrease in the pulse rate. Administer low-dose barbiturates. The head of the bed elevated 30 to 45 degrees. 3. The constituents of CSF are similar to those of blood plasma. Changes in level of consciousness. 2. Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. A nurse obtains a specimen of clear nasal drainage from a client with a head injury. and dilated. Give the client a warming blanket. asymmetric chest movements. fixed pupils occur later if the increased ICP is not treated. 3. 3. 2. 4. 5. Fluid volume and inotropic drugs are used to maintain cerebral perfusion by supporting the cardiac output and keeping the cerebral perfusion pressure greater than 80 mm Hg. Restrict fluids. 4. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm Hg? 1. 4. Specific gravity. 8. 2. . Which of the following is an early indicator of deterioration in the client's condition? 1. which reduces CSF and blood volume. client has signs of increased ICP.Neural control of respiration takes place in the brain stem. Microorganisms. pH. 7. The head elevated on two pillows. Glucose. decrease in the pulse rate. CSF contains glucose. Encourage the client to hyperventilate. Hyperventilation causes vasoconstriction. Decrease in level of consciousness. may be subtle. 6. Left Simm's position. such as restlessness and irritability. fixed pupil. A decrease in the client's level of consciousness is an early indicator of deterioration of the client's neurologic status. An examination for glucose content is done to determine whether body fluid is mucus or CSF. and nasal flaring are more characteristic of respiratory distress or hypoxia. shallow respirations. 2. Which client position would be most appropriate? 1. Dilated. Deterioration and pressure produce irregular respiratory patterns. A cooling blanket is used to control the elevation of temperature because a fever increases the metabolic rate. 3. which in turn increases ICP. Which of the following tests differentiates mucus from cerebrospinal fluid (CSF)? 1. 4. two important factors for reducing a sustained ICP of 20 mm Hg. Widening of the pulse pressure. Trendelenburg's position. The client has a sustained ICP of 20 mm Hg. High doses of barbiturates may be used to reduce the increased cellular metabolic demands. Widening pulse pressure.

the nurse closely monitors intake and output. After administering mannitol (Osmitrol).The client's ICP is elevated. not muscle relaxation." 2. all of which would increase her agitation and increase ICP. The Simm's position (side lying) and elevating the head on two pillows may extend or flex the neck. but the first comments should let the client know where he is and what happened to him. Pupil dilation. 3. Signs such as widening of the pulse pressure and pupil dilation should not occur. Deep breathing. person. Place her in a jacket restraint. Which parameter requires close monitoring? 1. Using a jacket or wrist restraint or tucking the client's arms and hands under the drawsheet restrict movement and add to feelings of being confined. A client who is regaining consciousness after a craniotomy becomes restless and attempts to pull out her intravenous line. The head of the bed is usually elevated 30 to 45 degrees to drain the venous sinuses and thus decrease the ICP. Offering to get his family and asking him questions to determine whether he is oriented are important. A male client with a head injury regains consciousness after several days. 10. Which activity would the nurse encourage the client to avoid when there is a risk for increased ICP? 1. Muscle relaxation. 2. "Can you tell me your name and where you live?" 3. "I'll get your family. Which nursing intervention protects the client without increasing her ICP? 1. 9. 2. and the client should be positioned to avoid extreme neck flexion or extension. because mannitol promotes diuresis and is given primarily to pull water from the extracellular fluid of the edematous brain. which increases ICP. 4. Which of the following nursing statements is most appropriate as the client awakens? 1. Wrap her hands in soft "mitten" restraints. Widening of the pulse pressure. The nurse administers mannitol (Osmitrol) to the client with increased ICP. 11. . because the mannitol serves to decrease ICP. Apply a wrist restraint to each arm. 4. 12. but making a comment such as "I'll bet you're a little confused" when he first awakens is not helpful and may cause him anxiety. Tuck her arms and hands under the draw sheet. You were in an accident and unconscious. "You are in the hospital." It is important to first explain where a client is to orient him to time. 3. It is useful to be empathetic to the client. Intake and output. and place." 4. Trendelenburg's position places the client's head lower than the body. which would increase ICP. Mannitol can cause hypokalemia and may lead to muscle contractions. It is best for the client to wear mitts which help prevent the client from pulling on the IV without causing additional agitation. "I'll bet you're a little confused right now.

or pons and is demonstrated clinically by arching of the back. pronation of the arms. wrists. Which of the following rehabilitation outcomes would be appropriate for the client? 1. Internal rotation and adduction of arms with flexion of elbows. Back arched. 3. Blood gas analysis and blood glucose levels will not reveal diabetes insipidus. 4. 13. Checking blood glucose. 3. The condition may occur in conjunction with head injuries as well as with other disorders. Deep breathing can be continued. 14. 4. Which of the following describes decerebrate posturing? 1. Internal rotation and . 15. Assessing arterial blood gas values every other day. midbrain. Measuring the urine output to detect excess amount and checking the specific gravity of urine samples to determine urine concentration are appropriate measures to determine the onset of diabetes insipidus. altered vital signs in a patient with a head injury may occur for other reasons as well. Measuring urine output hourly. Decerebrate posturing occurs in patients with damage to the upper brain stem. Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury. however. 2. rigid extension of all four extremities. The client will be able to return to his construction job in 3 weeks. clients who are transferred to rehabilitation facilities most likely will continue to exhibit cognitive and mobility impairments as well as behavior and personality changes. In ADH deficiency. rigid extension of the extremities. Diabetes insipidus results from deficiency of antidiuretic hormone (ADH). 4. The client will actively participate in the rehabilitation process as appropriate. 2. and plantar flexion of the feet. The client will be emotionally stable and display pre-injury personality traits. Which of the following is most effective in assessing the client suspected of developing diabetes insipidus? 1. Family members and significant others will need long-term support to help them cope with the changes that have occurred in the client. 2. The client will exhibit no further episodes of short-term memory loss. A client who had a serious head injury with increased ICP is to be discharged to a rehabilitation facility. Taking vital signs every 2 hours. Back hunched over. Coughing. dorsiflexion of the feet. Turning. 3.2. Coughing is contraindicated for a client at risk for increased ICP because coughing increases ICP. The patient may be tachycardic and hypotensive from fluid deficit. Passive range-of-motion exercises. 3. and fingers. The client would be expected to participate in the rehabilitation efforts to the extent he is capable. 4. Turning and passive range-of-motion exercises can be continued with care not to extend or flex the neck. Supination of arms. the client is extremely thirsty and excretes large amounts of highly diluted urine. rigid flexion of all four extremities with supination of arms and plantar flexion of feet.

The physician is notified immediately so that treatment can begin before respirations cease. Elevating the head of the bed to 30 degrees. Count the rate to be sure that ventilations are deep enough to be sufficient. Which action would be most appropriate? 1. resulting in sudden death. 3. Check deep tendon reflexes to determine the best motor response. which is just superior and posterior to the pons and medulla. clinical manifestations that indicate a new lesion are monitored very closely in case another bleed ensues. is used for supratentorial craniotomies. 2. Because the client had a bleed in the occipital lobe. Another nurse needs to assess vital signs and score the client according to the Glasgow Coma Scale. Elevation of the head of the bed to 30 degrees with the head turned to the side opposite the incision. 4. client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. 16. Cluster breathing consists of clusters of irregular breaths followed by periods of apnea on an irregular basis. which of the following is contraindicated when positioning the client? 1. 17. Keeping the client flat on one side or the other. Log rolling or turning as a unit when turning. In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy. which indicates damage to corticospinal tracts and cerebral hemispheres. Checking deep tendon reflexes is one part of the Glasgow Coma Scale analysis. if not contraindicated by the ICP. Keeping the neck in a neutral position. but time is also of the essence. . 4. and fingers describes decorticate posturing. 2.adduction of arms with flexion of elbows. 3. Call the physician while another nurse checks the vital signs and ascertains the patient's Glasgow Coma Scale score. Call the physician to adjust the ventilator settings. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Elevating the head of the bed to 30 degrees is contraindicated for infratentorial craniotomies because it could cause herniation of the brain down onto the brain stem and spinal cord. wrists.