Nursing Care for Traumatic Brain Injuries: Glasgow Scale, Symptoms, Treatment, Exams of Nursing

Download Nursing Care for Traumatic Brain Injuries: Glasgow Scale, Symptoms, Treatment and more Exams Nursing in PDF only on Docsity! A nursing student studying traumatic brain injuries (TBIs) should recognize which facts about these disorders? (Select all that apply.) 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 head injuries can cause a 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. 2) A nurse cares for older clients who have traumatic brain injury. What should the nurse understand about this population? (Select all that apply.) A. Admission can overwhelm the coping mechanisms for older clients. B. Alcohol is typically involved in most traumatic brain injuries for this age group. C. These clients are more susceptible to systemic and wound infections. D. Other medical conditions can complicate treatment for these clients. E. Very few traumatic brain injuries occur in this age group. 3) A client has meningitis following brain surgery. What comfort measures may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Applying a cool washcloth to the head B. Assisting the client to a position of comfort C. Keeping voices sof t and soothing D. Maintaining low lighting in the room E. Providing antipyretics for fever 4) A client has a small-bore feeding tube (Dobhoff tube) inserted for continuous enteral feedings while recovering from a traumatic brain injury. What actions should the nurse include in the client’s care? (Select all that apply.) A. Assess tube placement per agency policy. B. Keep the head of the bed elevated at least 30 degrees. C. Listen to lung sounds at least every 4 hours D. Run continuous feedings on a feeding pump. E. Use blue dye to determine proper placement. 5) A nurse is dismissing a client from the emergency department who has a mild traumatic brain injury. What information obtained from the client represents a possible barrier to self- management? (Select all that apply.) A. Does not want to purchase a thermometer B. Is allergic to acetaminophen (Tylenol) Correct C. Laughing, says “Strenuous? What’s that?” D. Lives alone and is new in town with no friends Correct E. Plans to have a beer and go to bed once home Correct 6) The nurse is evaluating the collaborative care of a client with traumatic brain injury (TBI). What is the most important goal for this client? A. Achieving the highest level of functioning 12) A client is admitted with a brain abscess. Which diagnostic assessment intervention does the nurse question as nonspecific to the diagnosis? A. Bone scan B. Electroencephalogram (EEG) C. Throat culture D. Sinus x-rays 13) A nurse prepares to provide perineal care to a client with meningococcal meningitis. Which personal protective equipment should the nurse wear? (Select all that apply.) A. Particulate respirator B. Isolation gown C. Shoe covers D. Surgical mask Correct E. Gloves Correct 14) A nurse is caring for a client with meningitis. Which laboratory values should the nurse monitor to identify potential complications of this disorder? (Select all that apply.) A. Sodium level B. Liver enzymes C. Clotting factors D. Cardiac enzymes E. Creatinine level 15) A nurse assesses a client who has encephalitis. Which manifestations should the nurse recognize as signs of increased intracranial pressure (ICP), a complication of encephalitis? (Select all that apply.) A. Photophobia B. Dilated pupils Correct C. Headache D. Widened pulse pressure Correct E. Bradycardia Correct 16) A nurse evaluates the results of diagnostic tests on a client’s cerebrospinal fluid (CSF). Which fluid results alerts the nurse to possible viral meningitis? (Select all that apply.) A. Clear Correct B. Cloudy C. Increased protein level Correct D. Normal glucose level Correct E. Bacterial organisms present F. Increased white blood cells 17) A nurse assesses a client with a spinal cord injury at level T5. The client’s blood pressure is 184/95 mm Hg, and the client presents with a flushed face and blurred vision. Which action should the nurse take first? A. Initiate oxygen via a nasal cannula. B. Place the client in a supine position. C. Palpate the bladder for distention. D. Administer a prescribed beta blocker. 18) An emergency room nurse initiates care for a client with a cervical spinal cord injury who arrives via emergency medical services. Which action should the nurse take first? A. Assess level of consciousness. B. Obtain vital signs. C. Administer oxygen therapy. D. Evaluate respiratory status. 19) An emergency department nurse cares for a client who experienced a spinal cord injury 1 hour ago. Which prescribed medication should the nurse prepare to administer? A. Intrathecal baclofen (Lioresal) B. Methylprednisolone (Medrol) C. Atropine sulfate D. Epinephrine (Adrenalin) 20) A nurse teaches a client with a lower motor neuron lesion who wants to achieve bladder control. Which statement should the nurse include in this client’s teaching? A. “Stroke the inner aspect of your thigh to initiate voiding.” B. “Use a clean technique for intermittent catheterization.” D. “I may urinate with ejaculation but this will not cause infection.” E. “I should be able to have an erection with stimulation.” 27) A nurse assesses a client with paraplegia from a spinal cord injury and notes reddened areas over the client’s hips and sacrum. Which actions should the nurse take? (Select all that apply.) A. Apply a barrier cream to protect the skin from excoriation. B. Perform range-of-motion (ROM) exercises for the hip joint. C. Re-position the client off of the reddened areas. D. Get the client out of bed and into a chair once a day. E. Obtain a low-air-loss mattress to minimize pressure. 28) A nurse assesses a client who experienced a spinal cord injury at the T5 level 12 hours ago. Which manifestations should the nurse correlate with neurogenic shock? (Select all that apply.) A. Heart rate of 34 beats/min Correct B. Blood pressure of 185/65 mm Hg C. Urine output less than 30 mL/hr Correct D. Decreased level of consciousness Correct E. Increased oxygen saturation 29) A nurse plans care for a client with a halo fixator. Which interventions should the nurse include in this client’s plan of care? (Select all that apply.) A. Tape a halo wrench to the client’s vest. B. Assess the pin sites for signs of infection. C. Loosen the pins when sleeping. D. Decrease the client’s oral fluid intake. E. Assess the chest and back for skin breakdown. 30) A client is admitted with Guillain-Barré syndrome (GBS). What assessment takes priority? A. Bladder control B. Cognitive perception C. Respiratory system D. Sensory functions 31) The nurse learns that the pathophysiology of Guillain-Barré syndrome includes segmental demyelination. The nurse should understand that this causes what? A. Delayed afferent nerve impulses B. Paralysis of affected muscles C. Paresthesia in upper extremities D. Slowed nerve impulse transmission 32) A client with Guillain-Barré syndrome is admitted to the hospital. The nurse plans caregiving priority to interventions that address which priority client problem? A. Anxiety B. Low fluid volume 39) A client with myasthenia gravis (MG) asks the nurse to explain the disease. What response by the nurse is best? A. “MG is an autoimmune problem in which nerves do not cause muscles to contract.” B. “MG is an inherited destruction of peripheral nerve endings and junctions.” C. “MG consists of trauma-induced paralysis of specific cranial nerves.” D. “MG is a viral infection of the dorsal root of sensory nerve fibers 40) A client with myasthenia gravis is prescribed pyridostigmine (Mestinon). What teaching should the nurse plan regarding this medication? (Select all that apply.) A. “Do not eat a full meal for 45 minutes after taking the drug.” Correct B. “Seek immediate care if you develop trouble swallowing.” Correct C. “Take this drug on an empty stomach for best absorption.” D. “The dose may change frequently depending on symptoms.” Correct E. “Your urine may turn a reddish-orange color while on this drug.” 41) A client has been diagnosed with Bell’s palsy. About what drugs should the nurse anticipate possibly teaching the client? (Select all that apply.) A. Acyclovir (Zovirax) B. Carbamazepine (Tegretol) C. Famciclovir (Famvir) D. Prednisone (Deltasone) E. Valacyclovir (Valtrex) 42) A client with myasthenia gravis is malnourished. What actions to improve nutrition may the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.) A. Assessing the client’s gag reflex B. Cutting foods up into small bites C. Monitoring prealbumin levels D. Thickening liquids prior to drinking E. Weighing the client daily 43) An older adult client is hospitalized with Guillain-Barré syndrome. The client is given amitriptyline (Elavil). After receiving the hand-off report, what actions by the nurse are most important? (Select all that apply.) A. Administering the medication as ordered B. Advising the client to have help getting up C. Consulting the provider about the drug D. Cutting the dose of the drug in half E. Placing the client on safety precautions 44) The nurse caring for a client with Guillain-Barré syndrome has identified the priority client problem of decreased mobility for the client. What actions by the nurse are best? (Select all that apply.) A. Ask occupational therapy to help the client with activities of daily living. B. Consult with the provider about a physical therapy consult. C. Provide the client with information on support groups. D. Refer the client to a medical social worker or chaplain. E. Work with speech therapy to design a high-protein diet. 45) A client’s mean arterial pressure is 60 mm Hg and intracranial pressure is 20 mm Hg. Based on the client’s cerebral perfusion pressure, what should the nurse anticipate for this client? A. Impending brain herniation B. Poor prognosis and cognitive function C. Probable complete recovery D. Unable to tell from this information 46) A client has a traumatic brain injury. The nurse assesses the following: pulse change from 82 to 60 beats/min, pulse pressure increase from 26 to 40 mm Hg, and respiratory irregularities. What action by the nurse takes priority? A. Call the provider or Rapid Response Team. B. Increase the rate of the IV fluid administration. C. Notify respiratory therapy for a breathing treatment. D. Prepare to give IV pain medication. 47) A nurse is caring for four clients in the neurologic intensive care unit. After receiving the provide further education on home care? A. “I know I can take care of all these needs by myself.” B. “I need to seek counseling because I am very angry.” C. “Hopefully things will improve gradually over time.” D. “With respite care and support, I think I can do this.” 53) A client in 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’s record. C. Give the prescribed pre procedure sedation. D. Notify the provider of the findings immediately. 54) After a craniotomy, the nurse assesses the client and finds dry, sticky mucous membranes and restlessness. The client has IV fluids running at 75 mL/hr. What action by the nurse is best? A. Assess the client’s magnesium level. B. Assess the client’s sodium level. C. Increase the rate of the IV infusion. D. Provide oral care every hour. 55) A nurse assesses a client with the National Institutes of Health (NIH) Stroke Scale and determines the client’s score to be 36. How should the nurse plan care for this client? A. The client will need near-total care. B. The client will need cuing only. C. The client will need safety precautions. D. The client will be discharged home. 56) A client has a brain abscess and is receiving phenytoin (Dilantin). The spouse questions the use of the drug, saying the client does not have a seizure disorder. What response by the nurse is best? A. “Increased pressure from the abscess can cause seizures.” B. “Preventing febrile seizures with an abscess is important.” C. “Seizures always occur in clients with brain abscesses.” D. “This drug is used to sedate the client with an abscess.”