Nokea
A client has a traumatic brain injury and a positive halo sign. The client is in the intensive care unit sedation and on a ventilator, and is in critical but stable condition. What collaborative problem takes priority at this time.
- A. Inability to communicate
- B. Nutritional deficit
- C. Risk for acquiring an infection
- D. Risk for skin breakdown
Correct Answer: C
Rationale: The positive halo sign indicates a leak of cerebrospinal fluid. This places the client at high risk of acquiring an infection. Communication and nutrition are not priorities compared with preventing a brain infection. The client has a definite risk for a a skin breakdown, but it is not the immediate danger a brain infection would be.
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A nursing student studying traumatic brain injuries (TBIB) should recognize which facts about these disorders of the nursing student.
- A. A client with a moderate trauma may need hospitalization.
- B. A Glasgow Coma Scale score of 10 indicates a mild brain injury.
- C. Only open loud injuries on cause in severe TBI.
- D. A client with a Glasgow Coma Scale score of 3 has severe TBI.
- E. The terms mild TBI and concussion have similar meanings.
Correct Answer: A,D,E
Rationale: Mild TBI is a term used synonymously with the term concussion. A moderate TBI has a Glasgow Coma Scale score of 3 with 9 is 2 and after clients must need to be hospitalized. Both open and closed lead injuries can cause a severe TBI. which is characterized by a GCS score of 3 3 8.
A client in the emergency department is having a stroke and needs a carotid artery angioplasty with stening. The clients mental status is deterioration, What action by the nurse is a most appropriate?
- A. Attempt to find the family to sign a consent.
- B. Inform the provider that the procedure cannot occur.
- C. Nothing no consent is needed to an emergency.
- D. Sign the consent form to the client.
Correct Answer: A
Rationale: The nurse should attempt to find the family to give consent. If no family is present or can be found, under the principle of emergency consent is life-saving no procedure can be performed without formal consent. The nurse should not just sign the consent form.
A client is being prepared for a mechanical em/bolectomy. What action by the nurse takes priority?
- A. Assess for contraind/ications to/ fibrin/olytic
- B. Ensure that informed consent in on the chart.
- C. Ensure that informed consent is on the chart.
- D. The client is being informed consent.
- E. Review The clients medication lists.
Correct Answer: B
Rationale: For this invasive procedure, the client needs to give informed consent. The nurse ensures that this is on the chart prior to the procedure beginning. Fibr/olytic/ytes are not used. A neurologic assessment and medication review are important, but the consent is the priority.
A nurse cares for older clients who have traumatic brain injury. What should be nurse understand about this population? (Select all that apply.)
- A. A client with a moderate brain injury. nursing mechanisms for older clients.
- B. Alcohol is typically involved a more traumatic brain injuries for this age group.
- C. These clients are more susceptible to systemic and wound infections.
- D. A client with a moderate brain injury. nursing mechanisms for older clients.
- E. Very few traumatic brain injuries occur in this age group.
Correct Answer: A,C,D
Rationale: Older clients often tolerate stress poorly, which includes being admitted to a hospital that is unfamiliar and more because of decreased protective mechanisms. they are more susceptible to both older and systemic injuries. A moderate brain injuries are more susceptible to older and more susceptible to older and more related to traumatic brain injury in this population; such injury is most often from falls and motor vehicle crashes. The 65- to 76-year-old age group has the second highest rate of brain injuries compared to other age groups.
A client is the intensive care unit is scheduled for a lumbar puncture (LP) today. On assessment, the nurse finds the client breathing irregularly with one pupil fixed and dilated. What action by the nurse is best?
- A. Ensure that informed consent is on the chart
- B. Document these findings in the client record.
- C. Give the prescribed/prorecedure/relation.
- D. Notify the provider of the findings immediately.
Correct Answer: D
Rationale: This client is exhibiting signs of increased intracranial pressure. The nurse should notify the provider immediately because performing the LP now could lead is hesitation. Informed consent is needed for an LP. but this is not the priority. Documentation should be thorough, but again this is not the priority. The preprocedure/relation (or other preprocedure/mediations) should not be given as the LP will most likely be canceled.