Head Injury Jean Flick, RN, MS Basilar Skull Fracture A basilar skull fracture is a linear skull fracture that extends over the base of the frontal and temporal lobes. The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently. 1. Which assessment technique allows the nurse to assess for Battle's sign? A) Assess Jeff's pupillary response to light. INCORRECT This is an important part of the neurologic assessment, but it does not demonstrate a positive Battle's sign.
B) Observe the area behind Jeff's ears. CORRECT Battle's sign refers to ecchymosis behind the ears, and it is a common manifestation of a basilar skull fracture.
C) Observe the area around Jeff's eyes. INCORRECT Periorbital ecchymosis, also called "raccoon eyes" is a common manifestation of a basilar skull fracture, along with a positive Battle's sign.
D) Test Jeff's ability to follow directions. INCORRECT This is an important part of the neurologic assessment, but it does not demonstrate a positive Battle's sign. Correct answer(s): B Other manifestations of a basilar skull fracture include tinnitus, facial paralysis, hearing difficulty, epistaxis, and CSF (cerebral spinal fluid) leakage from the nose or ears. The nurse is concerned about the rhinorrhea that Jeff is experiencing. 2. What methods can the nurse use to determine if the drainage is CSF? A) Measure the specific gravity of the drainage. INCORRECT This is not useful in determining the type of draining fluid.
B) Measure the spinal fluid pressure. INCORRECT This is done during a lumbar puncture, where an increased pressure is an indicator of increased ICP.
C) Observe for a "halo" around a spot of drainage. CORRECT When a drop of the drainage is placed on a white dressing, the CSF will separate from the blood and form a "halo" around the blood. Other measures the nurse can use include observing the appearance of the drainage and using a dextrostick to assess for the presence of glucose in the drainage. CSF is clear. However, the CSF may be mixed with blood, so appearance alone may not be a true indicator of CSF. CSF contains glucose, unlike normal nasal drainage. However, a false positive for glucose may be obtained if the CSF is mixed with blood, since blood also contains glucose!
D) Measure the quantity of the drainage. INCORRECT This is an important measure, but it will not determine whether the drainage is CSF. Correct answer(s): C Nursing Plans and Interventions The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial pressure (ICP). 3. Which nursing intervention should be initiated to prevent increased ICP? A) Apply a hyperthermia blanket. INCORRECT Increasing the body's temperature increases cerebral blood flow, and this should be avoided. If the client develops an elevated temperature, cooling measures such as antipyretics and cold packs should be instituted immediately to reduce the fever.
B) Administer a prescribed stool softener as needed (PRN). CORRECT Activities such as performing a Valsalva maneuver, coughing, and vomiting should be prevented, since these cause an increase in ICP. In addition, the client should be positioned with the head of the bed elevated about 30 degrees, and neck flexion and extension should be avoided.
C) Keep wrist restraints in place. INCORRECT Restraints should not be used, because straining against restraints may cause increased ICP. Clients with head injury are frequently sedated with hypnotic medications, such as propofol (Diprivan), to prevent restlessness and increased ICP that may occur.
D) Pack the nares with sterile gauze. INCORRECT Packing the nares will prevent the CSF from draining and may cause an increase in ICP. The drainage should be caught using a sterile drip pad. Correct answer(s): B Jeff requests "something for his headache." 4. Which medication is best for the nurse to administer to Jeff for his complaint of headache? A) Morphine sulfate. INCORRECT Morphine is an opioid analgesic. Opioids should be avoided following head trauma of any kind, including a concussion, because opioids can cause CNS depression and may mask symptoms of increasing ICP.
B) Oxycodone/aspirin (Percodan). INCORRECT Percodan is an opioid analgesic. Opioids should be avoided following head trauma of any kind, including a concussion, because opioids can cause CNS depression and may mask symptoms of increasing ICP.
C) Hydrocodone/acetaminophen (Lortab). INCORRECT Hydrocodone is an opioid analgesic. Opioids should be avoided following head trauma of any kind, including a concussion, because opioids can cause CNS depression. However, if a non-opioid analgesic does not relieve the client's pain, a hydrocodone product may be used, since CNS depression is less likely to occur with these than with other opioids.
D) Acetaminophen (Tylenol). CORRECT This is the best choice, because Tylenol is a non-opioid analgesic, and it will not cause CNS depression. Correct answer(s): D Glasgow Coma Scale (GCS) 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). About an hour later, Jeff's Glascow Coma Scale rating changes from 13 to 10. 5. What does this indicate to the nurse? A) Improved neurologic status. INCORRECT 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.
B) Diminished neurologic status. CORRECT 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 notification of the physician.
C) Comatose state. INCORRECT A comatose state usually occurs with a score of 7 or less.
D) Irreversible brain damage. INCORRECT Clients with scores greater than 8 have a good prognosis for recovery. Correct answer(s): B 6. What are the three components measured by the GCS? A) Verbal response, motor response, and eye opening. CORRECT The GCS measures responses that are spontaneous and completely oriented to responses only from noxious stimuli to no response at all. The client is observed for abnormal decorticate (flexor) and decerebrate (extensor) posturing as part of the motor response to a stimulus.
B) Seizure activity, muscle strength, and posturing. INCORRECT Although seizure activity and diminished muscle strength may occur as the result of increased ICP, these are not measured by the GCS.
C) Gag reflex, blink reflex, and Babinski reflex. INCORRECT These reflexes may be assessed as part of the neurologic assessment, but they are not measured by the GCS.
D) Pupillary response, visual field, and eye movement. INCORRECT These are important neurologic parameters, but they are not measured by the GCS. Correct answer(s): A Increased Intracranial Pressure In addition to a deteriorating GCS, Jeff begins to exhibit additional clinical manifestations of increasing intracranial pressure. Increased intracranial pressure (ICP) is the leading cause of death from head trauma for those individuals who survive the initial trauma and make it to the hospital. 7. What is the most important indicator of increasing ICP? A) Fixed, dilated pupils. INCORRECT Pupillary changes, including an increase or decrease in size or change in responsiveness, are indicators of increased ICP, but they are not usually the first indicator, nor are they considered the most important indicator.
B) Hypertension. INCORRECT High blood pressure, bradycardia, and a widening pulse pressure are significant, but late, indicators of increased ICP.
C) Change in level of consciousness. CORRECT A change in LOC is the single most significant indicator of deterioration in neurologic function.
D) Cheyne-Stokes respiration. INCORRECT Altered respiratory patterns, such as Cheyne-Stokes respiration, may be an indication of increasing ICP, but they are not the most important indicator. Correct answer(s): C Priority nursing diagnoses when planning care for a client with increased ICP include: • Decreased Intracranial adaptive capacity. • Ineffective Tissue perfusion (cerebral). • Disturbed Sensory perception (tactile). • Risk for Injury. The physician prescribes the following for Jeff: • 0.9 Normal Saline at 30 ml/hour. • 15% Mannitol (Osmitrol) IVPB q12 hours. • Fuorsemide (Lasix) 40 mg IVP following Mannitol. • Dexamethasone (Decadron) 4 mg IVP q6 hours. • Phenytoin (Dilantin) 100 mg IVP q8 hours. 8. Which of these medications should not be mixed with any other medication, or any IV solution other than normal saline? A) Mannitol (Osmitrol). INCORRECT This is an osmotic diuretic.
B) Furosemide (Lasix). INCORRECT Furosemide is an antihypertensive agent and a loop diuretic. A Direct IV should be administered undiluted slowly over 10 to 20 minutes. Dilute large doses in D5W, D10W, D20W, D5/0.9% NaCl, D5/LR 0.9% NaCl, 3% NaCl, 1/6 M Sodium Lactate or Lactated Ringer's solution. Use reconstituted solution within 24 hours.
C) Dexamethasone (Decadron). INCORRECT This is a glucocorticoid.
D) Phenytoin (Dilantin). CORRECT Dilantin may be used after head injury to prevent seizure activity. A precipitate is formed when Dilantin is mixed with other medications, so Dilantin should be administered by itself, and the IV tubing should be flushed with normal saline before and after drug administration. Correct answer(s): D 9. Which nursing intervention should the nurse include when administering the Mannitol? A) Monitor serum glucose levels. INCORRECT This is an important intervention for the corticosteroid (dexamethasone), but it is not necessary for the administration of Mannitol.
B) Cross-check the client's blood type. INCORRECT This is not necessary when administering Mannitol, which is not a blood product.
C) Use IV tubing with a filter. CORRECT Mannitol is a hypertonic solution used to reduce intracranial pressure. Mannitol is often given with a diuretic, such as Lasix. It should be administered undiluted, but through a filter to prevent the administration of any particulates.
D) Administer via a central line. INCORRECT Mannitol does not need to be administered through a central line. Correct answer(s): C The nurse administers the normal saline using an electronic controller and a buretrol. 10. This method of administration is chosen to reduce the risk of: A) Thrombophlebitis. INCORRECT Thrombophlebitis, or inflammation of a vein accompanied by formation of a clot, is commonly caused by placement of a needle or catheter for intravenous (IV) therapy. Using the controller and a buretrol will not reduce the risk of thrombophlebitis following placement of the IV.
B) Anaphylactic shock. INCORRECT Anaphylactic shock, a result of a Type I hypersensitivity reaction, is caused by exposure to an antigen which causes a massive, life-threatening allergic response. The use of a controller and a buretrol will not prevent anaphylactic shock.
C) Infiltration. INCORRECT Infiltration results from migration of an intravenous (IV) needle or catheter out of the vein and into the interstitial tissue. As a result, the IV fluid seeps into the interstitium until the IV is stopped, causing discomfort and edema at the site. The use of a controller and a buretrol may reduce the amount of fluid infused into the tissue with infiltration of the IV, but they do not prevent the IV from infiltrating.
D) Fluid overload. CORRECT The client with increased ICP requires very careful administration of IV fluids to avoid fluid volume overload, which would increase ICP. Using an electronic controller and a buretrol will reduce the risk of fluid overload. Correct answer(s): D Subdural Hematoma The CT scan reveals that Jeff has an acute subdural hematoma. He is taken to the Operating Room for drainage via burr holes. A subdural hematoma is a venous bleed below the dura matter of the brain. It can be acute (within 48 hours of the initial head injury), sub-acute (occurring up to 2 weeks after the injury), or chronic (occurring between 2 weeks and 2 months after the injury). Since a subdural bleed is venous, it typically develops more slowly than an epidural bleed, which is usually arterial. This bleeding results in a space-occupying hematoma that creates pressure on the brain and results in increased intracranial pressure. Treatment includes evacuation of the hematoma with resultant decompression of the brain. This is done via burr holes, or, for large or chronic hematomas, via craniotomy. Following surgery, Jeff is transferred to the Critical Care Unit. He is placed on mechanical ventilation. 11. Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP? A) PO2 of 85 and PCO2 of 55. INCORRECT It is desirable to maintain the PO2 closer to 100 to prevent cerebral hypoxia, and the PCO2 is too high. Remember, CO2 is a potent vasodilator.
B) PO2 of 95 and PCO2 of 45. INCORRECT The PO2 level should be maintained close to 100 to prevent cerebral hypoxia, however, the PCO2 level is too high.
C) PO2 of 95 and PCO2 of 35. CORRECT 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. Previously, aggressive hyperventilation was used to maintain PCO2 levels of less than 35, since this promotes vasoconstriction thereby reducing ICP. However, studies have shown that aggressive hyperventilation may contribute to focal cerebral ischemia.
D) PO2 of 85 and PCO2 of 15. INCORRECT The PO2 should be maintained closer to 100 to prevent cerebral hypoxia, and while the PCO2 is at a low level, it may further decrease cerebral oxygenation. Correct answer(s): C 12. Which documentation indicates the expected outcome of the mechanical ventilation was achieved? A) Client exhibits no symptoms of increased ICP. CORRECT The goal of hyperventilation is to maintain cerebral oxygenation and prevent an increase in ICP by maintaining the PCO2 at a low normal level.
B) Client's ABG results are within normal limits (WNL). INCORRECT There is a better choice.
C) Client's Hemoglobin and Hematocrit are stable. INCORRECT This is an important postoperative outcome, but it is not related to mechanical ventilation.
D) Client's breath sounds are clear bilaterally. INCORRECT Although this is certainly desirable, this is not the purpose of the mechanical ventilation. Correct answer(s): A Ethical-Legal Considerations 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. 13. What is the best response by the nurse? A) "Why do you want to keep this confidential?" INCORRECT Questions that start with "why" may be perceived as challenging, and they should be avoided. In addition, this response may lead Jeff to believe that the nurse is willing to keep all information confidential, which may not be true.
B) "I promise to keep whatever you tell me just between us." INCORRECT Since Jeff's parents are legally responsible for his care, knowledge which is harmful may need to be shared by the nurse. The nurse should not make a promise that may need to be broken.
C) "It is my professional duty to notify your healthcare provider of everything you tell me." INCORRECT This is not an accurate description of the nurse's responsibility.
D) "It is possible I may have to share some of what you tell me with others." CORRECT Since Jeff's parents are legally responsible for his care, knowledge which is harmful may need to be shared by the nurse. Correct answer(s): D Jeff shares with the nurse that he and his friends had a "couple of beers" the night of the accident. He states, "I guess I had to learn this lesson the hard way." Later that evening, the nurse discusses what Jeff has said with another nurse. This conversation takes place in the hospital cafeteria, where it is overheard. Since Jeff's family is prominent in the community, the information about alcohol use is "leaked" to the media, who call the nursing supervisor to confirm the report. 14. What is the primary concern the supervisor should consider prior to responding to the media? A) Is this reporter honest and trustworthy? INCORRECT This is not the supervisor's primary concern at this time.
B) Has the client authorized the release of information? CORRECT All clients have the right to confidentiality. It is the responsibility of the nurse to safeguard client information.
C) How did the media obtain information about the client? INCORRECT While the supervisor may wish to obtain this information for appropriate follow-up with the involved persons, this is not the primary concern.
D) Has an adverse occurrence report been filed? INCORRECT A breach of client confidentiality will not generally be documented on an adverse occurrence, or incident, report. Correct answer(s): B A Complication Occurs 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. 15. Which intervention should the nurse initiate? A) Respect Jeff's wishes to be left alone. INCORRECT Jeff is exhibiting manifestations of meningitis, a serious medical complication. Assessment and intervention should be initiated immediately by the nurse.
B) Ask the UAP to stay with Jeff until he is calmer. INCORRECT The nurse needs to assess Jeff immediately and stay with him while notifying the healthcare provider of this change in condition.
C) Administer an analgesic for his headache. INCORRECT This should not be done until Jeff is assessed and the healthcare provider notified of this change in condition.
D) Notify the healthcare provider of Jeff's symptoms. CORRECT Jeff is exhibiting symptoms of meningitis, a serious complication requiring immediate medical and nursing intervention. The nurse should gather additional assessment data, such as vital signs and neurologic status, and then notify the healthcare provider. Correct answer(s): D The nurse takes Jeff's vital signs and notes that he has a fever of 102° F, and that he reports pain upon flexion of his neck (nuchal rigidity). The healthcare provider is notified, and it is determined that Jeff has meningitis. Jeff is exhibiting the three classic manifestations of meningitis: fever, headache, and nuchal rigidity. In addition, he manifests irritability and photophobia, which are common symptoms of meningitis. 16. What additional clinical manifestation is often seen in bacterial meningitis? A) Distended neck veins. INCORRECT This is not a typical manifestation of meningitis.
B) Dilated pupils. INCORRECT This is not a typical manifestation of meningitis, although pupillary changes may occur if intracranial pressure increases.
C) Photosensitivity. INCORRECT Photosensitivity is increased reactivity of the skin to sunlight, and unlike photophobia, it is not typical of meningitis.
D) Rash. CORRECT Rashes commonly occur in meningitis, and they vary extensively in appearance from red macular rashes to large purpuric rashes. They are most frequently seen in areas where pressure is exerted, such as the axilla and groin. Correct answer(s): D A Medical Emergency The onset of bacterial meningitis is considered a medical emergency. Jeff is immediately started on IV antibiotics and placed in isolation for the first 24 hours after the initiation of his antibiotic therapy. Priority nursing diagnoses, all related to increasing intracranial pressure secondary to the inflammation and meningeal irritation include pain, ineffective tissue perfusion (cerebral), and risk for ineffective breathing pattern. 17. What additional nursing diagnosis is important to include when planning Jeff's care during this period? A) Urinary retention. INCORRECT This is not an expected problem in meningitis.
B) Risk for injury. CORRECT Clients with meningitis may experience seizures, and they are also at high risk for injury due to altered sensorium.
C) Ineffective airway clearance. INCORRECT This is not an expected problem in meningitis.
D) Impaired skin integrity. INCORRECT The skin is not damaged as the direct result of meningitis, although a prolonged recovery time may result in immobility, placing the client at risk for impaired skin integrity, this is not a priority consideration at this time. Correct answer(s): B Management Issues: Staffing assignments The next morning, the charge nurse is making nursing care assignments. Several tasks must be performed immediately, and only an RN and a UAP are available. 18. Which responsibility needs to be performed by the RN? A) Obtain vital signs of a client in isolation with meningitis. INCORRECT This responsibility can be performed by the UAP, although the RN will need to perform additional assessment and analysis of the vital signs.
B) Monitor a bleeding postoperative client who is receiving a blood transfusion. CORRECT The RN should be assigned this responsibility. Of the four tasks, this requires the highest level of expertise to assess the client's current condition and response to the treatment. (Always remember ABCs.)
C) Assist a weak preoperative client to the bathroom. INCORRECT This responsibility can be assigned to the UAP. Remember, UAPs' assignments must fall within the intervention component of the nursing process.
D) Ensure that visitors are adhering to isolation protocols. INCORRECT This responsibility can be assigned to the UAP. Remember, UAPs' assignments must fall within the intervention component of the nursing process. Correct answer(s): B Therapeutic Communication: Communicating with an Adolescent Jeff's condition gradually improves. He is no longer in isolation, and several of his friends are planning to visit him. Although Jeff's condition is improving, he reports occasional periods when he feels "fuzzy-headed," and he has trouble understanding all the words in a conversation. He tells the nurse he does not want to see any of his friends because "he's a freak who can't even think straight anymore." 19. Which statement about adolescents should guide the nurse's response? A) Adolescents have not yet developed the ability to reason. INCORRECT Adolescents, especially late adolescents (ages 17 – 19) have developed an ability to reason, and they often question the beliefs of others.
B) The focus of the late adolescent is entirely on oneself. INCORRECT The early adolescent (ages 13 – 15) is very egocentric, but the late adolescent (ages 17 – 19) has developed the ability to see another's perspective.
C) The developmental task of the adolescent is developing a sense of industry. INCORRECT This is the task of the school-aged child. The developmental task of the adolescent, according to Erickson, is achievement of one's identity.
D) The adolescent has a strong sense of peer group identity. CORRECT The adolescent becomes less reliant on the family and much more reliant on the peer group for a sense of identity. Correct answer(s): D 20. What is the nurse's best response to Jeff's refusal to see his friends? A) "If I were in your situation, I would want my friends around me." INCORRECT Giving advice is generally non-therapeutic, and it can sometimes be a block to further communication.
B) "I understand exactly what you are feeling right now." INCORRECT This expression belittles the client's feelings and is non-therapeutic.
C) "You are worried about how your friends will react to you." CORRECT This is a therapeutic response, which clarifies the client's concerns and allows for further communication.
D) "Your parents asked your friends to come here to see you." INCORRECT This non-therapeutic response creates a sense of guilt, which is a block to further communication. Correct answer(s): C Discharge Teaching The nurse has completed discharge teaching for Jeff and his parents. 21. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate? A) "I'll be as good as new in another few months." INCORRECT While a full recovery is possible, it is more likely that Jeff will experience some long-term residual effects from his head injury.
B) "I will always have some increased pressure in my brain because of this injury." INCORRECT Although it is likely that Jeff will experience some long-lasting residual effects from the head injury, they are not caused by continued ICP.
C) "I may have some long-lasting effects from this injury." CORRECT As a general rule, people who experience a major head injury are never "the same" again. Long-term effects may include altered cognitive, motor, sensory, or emotional functioning. Progressive recovery generally occurs for the first six months before a plateau is reached, and some problems, such as post-injury seizures, may not occur until several years after the injury.
D) "My parents will always have to take care of me now." INCORRECT Not necessarily. Following rehabilitation, persons with head injuries may lead successful, independent lives. Correct answer(s): C Risk Factors Jeff is discharged, accompanied by his parents. He continues to exhibit some impaired memory, occasional emotional outbursts, and difficulty following long conversations which seem to be related to post-traumatic syndrome. Jeff's nurse is invited to discuss risk factors related to head injury at Jeff's high school. 22. What is the most significant change in adolescent behavior needed to reduce head injuries? A) Avoid talking on cell phones while driving. INCORRECT This is certainly an important safety issue, but it is not the most important single risk factor.
B) Do not drive with more than one passenger in the car. INCORRECT This is certainly an important safety issue, especially for inexperienced adolescent drivers, but it is not the most important single risk factor.
C) Always designate a safe driver who will not drink. CORRECT Sixty percent of all head injuries are alcohol-related. The vast majority of these occur between the ages of 10 – 39, with the peak incidence between the ages of 15 – 24.
D) Avoid driving during dusk or after dark. INCORRECT This is certainly an important safety issue, especially for inexperienced adolescent drivers, but it is not the most important single risk factor. Correct answer(s): C Case Outcome To support further efforts to reduce teen-age drinking and driving, Jeff's parents establish a scholarship fund based on essays written by high school students regarding effective approaches to curb teen drinking.
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