Nokea
The nurse is caring for a client with a head injury after a fall. Which of the following indicates the presence of, or leaking of, cerebral spinal fluid?
- A. Change in the level of consciousness (LOC)
- B. Signs of increased intracranial pressure (IICP)
- C. Halo sign
- D. Swelling
Correct Answer: C
Rationale: To detect any CSF drainage, the nurse looks for a halo sign. If drainage is present, the nurse allows it to flow freely onto porous gauze and avoids tightly plugging the orifice. Change in the LOC and signs of IICP are part of the neurologic assessment and do not assist in detecting any CSF drainage. The presence of swelling does not assist in detecting CSF drainage.
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The intensive care unit has four clients received from a violent motor vehicle accident. Which client would the nurse assess first?
- A. The client with an open head injury
- B. The client with a basilar fracture
- C. The client with a concussion
- D. The client with a coup injury
Correct Answer: B
Rationale: Of the four clients, the client whom the nurse would assess first would be the client with a basilar fracture due to location of the fracture being at the base of the skull. This location is especially dangerous because it can cause edema of the brain near the spinal cord and can interfere with circulation of cerebral spinal fluid. An open head injury causes a potential for infection but are less likely to have an increased intracranial pressure. A concussion is a blow to the head that jars the brain. A coup injury occurs when the brain is struck directly.
The nurse is caring for a client experiencing autonomic dysreflexia. Which of the following does the nurse recognize as the source of symptoms?
- A. Autonomic nervous system
- B. Central nervous system
- C. Peripheral nervous system
- D. Sympathetic nervous system
Correct Answer: D
Rationale: The nurse recognizes that autonomic dysreflexia is an exaggerated sympathetic nervous system response. Symptoms include severe hypertension, slow heart rate, pounding headache, etc. and can lead to seizures, stroke, and death. The autonomic nervous system regulates 'feed and breed' functions. The central and peripheral nervous system is a component of the sympathetic nervous system.
When caring for a client who is post-intracranial surgery what is the most important parameter to monitor?
- A. Extreme thirst
- B. Intake and output
- C. Nutritional status
- D. Body temperature
Correct Answer: D
Rationale: It is important to monitor the client's body temperature closely because hyperthermia increases brain metabolism, increasing the potential for brain damage. Therefore, elevated temperature must be relieved with an antipyretic and other measures. Extreme thirst, intake and output, and nutritional status are not the most important parameters to monitor.
A 6-year-old child has come to the emergency department (ED) after falling off a bike. The health care provider diagnoses a concussion and the child's parent asks the nurse what a concussion is. What should the nurse's response be?
- A. A concussion is a blow to the head that bruises the brain.
- B. A concussion is a blow to the head that is hard enough for the brain to bounce off the other side of the skull.
- C. A concussion is a blow to the head that is minor and has no real consequences.
- D. A concussion is a blow to the head that jars the brain, resulting in diffuse and microscopic injury to the brain.
Correct Answer: D
Rationale: A concussion results from a blow to the head that jars the brain. It usually is a consequence of falling, striking the head against a hard surface such as a windshield, colliding with another person (e.g., between athletes), battering during boxing, or being a victim of violence. A concussion results in diffuse and microscopic injury to the brain. The other options are incorrect because they give incorrect information to the mother.
The nurse is caring for a postoperative client who had surgery to decrease intracranial pressure after suffering a head injury. Which assessment finding is promptly reported to the physician?
- A. The client has periorbital edema and ecchymosis.
- B. The client's vital signs are temperature, 100.9?°F; heart rate, 88 beats/minute; respiratory rate, 18 breaths/minute; and blood pressure, 138/80 mm Hg.
- C. The client's level of consciousness has improved.
- D. The client prefers to rest in the semi-Fowler's position.
Correct Answer: B
Rationale: The assessment finding promptly reported to the physician is the information which may cause complications. It is important to report the elevation in client temperature (100.9?°F) because hyperthermia increases brain metabolism, increasing the potential for brain damage. It is not unusual for the client to experience periorbital edema and ecchymosis secondary to the head injury and surgery. Improved level of consciousness is a positive outcome of the treatment provided. There is no complication related to semi-Fowler's position.