Question 1 of 10
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Which preexisting condition increases the risk for torn vessels and brain tissue contusion in the event of an accident with brain injury?
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- Brain atrophyBrain atrophy (shrinkage in size) can occur with aging and places the patient at risk for torn vessels and contusion on the brain in the event of an accident with brain injury.
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- HydrocephalusHydrocephalus can provide cushion to the brain in the event of an accident that involves brain injury. This condition could occur because of a brain injury, but it would not place the patient at more risk for torn vessels or contusion on the brain.
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- Heterotopic ossificationHeterotopic ossification may occur with long-term immobility; this is a bony overgrowth potentially involving muscle and considered a long-term complication of spinal injury. This would not place the patient at more risk for torn vessels or contusion on the brain.
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- Increased intracranial pressure (ICP)Increased ICP can provide cushion to the brain in the event of an accident that involves brain injury. This condition could occur because of a brain injury, but it would not place the patient at more risk for torn vessels or contusion on the brain.
Question 2 of 10
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Which potential complication related to a cerebral hemorrhage and edema would the nurse monitor for in a patient presenting with a head injury?
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- AnxietyAnxiety can result from an abrupt change in health status, being in a hospital environment, and having an uncertain future. This is not a complication related to a cerebral hemorrhage and edema.
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- HyperthermiaIncreased metabolism, infection, and hypothalamic injury can cause hyperthermia. This is not a complication related to a cerebral hemorrhage and edema.
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- Impaired physical mobilityImpaired physical mobility is related to a decreased level of consciousness. This is not a complication related to a cerebral hemorrhage and edema.
- Correct
- Increased intracranial pressure (ICP)Increased ICP can occur as a potential complication related to cerebral hemorrhage and edema.
Question 3 of 10
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Which method would the nurse utilize to determine the presence of papilledema in a patient with an increased intracranial pressure (ICP)?
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- Observing during skin assessmentA skin assessment is not an appropriate method when determining the presence or absence of papilledema.
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- Observing with an ophthalmoscopeThe nurse would view papilledema (swelling of the optic disc) with an ophthalmoscope. Papilledema is one of the classic signs of increased ICP.
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- Palpating around the orbital bone and socketPapilledema is the swelling of the optic disk, and palpation of the optic disc is not feasible.
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- Palpating the cranium, particularly around the earsPapilledema is the swelling of the optic disk, and palpation of the optic disc is not feasible.
Question 4 of 10
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What term describes a traumatic brain injury (TBI) that occurs when the head is moving rapidly and hits a stationary object?
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- ContusionA contusion is bleeding under the skin due to trauma, generally caused by a direct blow to the body.
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- ConcussionA concussion is a type of mild TBI caused by a violent blow to the head or violent shaking of the body. It can occur as a result of a coup-contrecoup injury.
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- Coup-contrecoupA coup-contrecoup, or acceleration-deceleration injury, occurs when the head is moving rapidly and hits a stationary object.
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- PenetratingA penetrating, or open head injury, occurs when there is a break in the skull.
Question 5 of 10
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Which finding is a manifestation of a concussion? Select all that apply. One, some, or all responses may be correct.
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- DizzinessDizziness is a common sign or symptom of a concussion.
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- Ecchymosis behind the earEcchymosis behind the ear, otherwise known as the Battle sign, can occur with a basilar skull fracture.
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- ConfusionConfusion and memory problems are a main sign or symptom of a concussion.
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- Feeling hazyFeeling sluggish, hazy, foggy, groggy, or just “not right” can occur with a concussion.
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- NauseaNausea or vomiting can be a common sign or symptom of a concussion.
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- OtorrheaOtorrhea, or fluid from the ears, can occur as a result of a basilar skull fracture.
Question 6 of 10
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Which type of traumatic brain injury would the nurse suspect when a patient presents with hydrocephalus after a motor vehicle accident?
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- Epidural hematomaAn epidural hematoma occurs when there is rapid leakage of blood from the middle meningeal artery into the space between the dura and the skull and is considered a medical emergency. This is not associated with hydrocephalus.
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- ContusionIn a contusion, the brain tissue is bruised, and blood from the broken vessels accumulates, causing edema. This is not associated with hydrocephalus.
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- Subarachnoid hemorrhageThe subarachnoid space is where the cerebrospinal fluid circulates, so any hemorrhage into this area circulates the blood throughout the spinal dural sac and predisposes the patient to developing hydrocephalus.
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- Subdural hematomaA subdural hematoma may rupture the blood vessels that lie between the arachnoid membrane and the dura mater. This is not associated with hydrocephalus.
Question 7 of 10
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Which assessment finding would cause the nurse to document a positive halo sign?
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- Cerebrospinal fluid (CSF) on a gauze padPresence of a pink spot surrounded by a yellow ring (halo) is indicative of CSF.
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- Blood in the urinePresence of blood in the urine is documented as hematuria.
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- Blood in the stoolPresence of blood in the stool is documented as hematochezia.
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- Clean, thin, watery drainage from a woundThe nurse would document clean, thin, watery drainage from a wound as serous drainage; it is the typical response from the body during the inflammatory stage of healing.
Question 8 of 10
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What assessment finding would the nurse expect in a patient diagnosed with an acute left-sided subdural hematoma?
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- Hemiplegia on the left sideWith a subdural hematoma, the patient will more likely present with hemiplegia on the contralateral (opposite) side of the injury.
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- Dilated left pupilWith a subdural hematoma, the patient may present with dilation of the pupil on the ipsilateral (same) side as the injury.
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- Dilated right pupilWith a left-sided subdural hematoma, the left pupil will be dilated.
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- Severe headacheA severe headache is a hallmark symptom of a subarachnoid hemorrhage not a subdural hematoma.
Question 9 of 10
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What classification of medications might be prescribed to decrease vascular volume and keep intracranial pressure (ICP) as low as possible?
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- AntiarrhythmicsAntiarrhythmic medications cause the heart muscles to relax through coronary vasodilation and could increase ICP.
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- Calcium channel blockersCalcium channel blockers are used to elicit arterial vasodilation and could potentially increase ICP.
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- Nonsteroidal antiinflammatory drugs (NSAIDs)NSAIDs are a class of medications used to treat inflammation; however, they have blood thinning properties, which are contraindicated with traumatic brain injuries.
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- DiureticsDiuretics are used to decrease the vascular volume and keep ICP as low as possible in patients with traumatic brain injury.
Question 10 of 10
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Which nursing action is the priority when caring for a patient with increased intracranial pressure (ICP)?
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- Provide suctioning to remove excess oral secretions.Patients with increased ICP may have a decreased LOC and decreased gag reflex. It is imperative to keep the airway open, which may require suctioning and potentially intubation and mechanical ventilation. Airway patency in the first priority of care for this patient.
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- Maintain the cervical spine in a neutral position.Maintaining the cervical spine in a neutral position is a critical component of the nursing care for a patient with increased ICP. This position is the most tolerable and least likely to further increase ICP. While very important, it is not prioritized above maintenance of a patent airway.
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- Begin nutritional supplementation if unable to take food orally.Nutritional support, when provided early, has been shown to improve outcomes following brain injury. Optimal nutrition promotes healing. If unable to take oral food, supplemental nutrition should be started within 72 hours of the injury. While very important, it is not prioritized above maintenance of a patent airway.
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- Provide a stool softener twice daily.Preventing constipation is a critical intervention when caring for a patient with increased ICP. Straining to have a bowel movement (Valsalva maneuver) can dangerously increase ICP and must be avoided. Patients are often treated with stool softeners for this purpose. While very important, it is not prioritized above maintenance of a patent airway.
