BIOLOGY 145HESI Case Studies--Medical/SurgicalTraumatic Brain Injury (Jeff Dickson) HESI Case Studies--Medical/Surgical-Traumatic Brain Injury (Jeff Dickson) 1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all) -Assess the equality of Jeff's pupils -Observe the area behind Jeff's ears -Observe the area around Jeff's eyes -Check Jeff's nasal cavity for leaking fluid 2. What methods can the nurse use to determine if the drainage is CSF? Observe for a "halo" around a spot of drainage. 3. Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)? Administer a prescribed stool softener as needed (PRN). 4. Jeff requests "something for his headache." Which medication is best for the nurse to administer to Jeff for his complaint of headache? Acetaminophen (Tylenol). 5. What are the three components measured by the GCS? Verbal response, motor response, and eye opening. 6. What is the Glascow Coma Scale rating obtained in this assessment. 10 7. About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse? Diminished neurologic status. 8. What is the most important indicator of increasing ICP? Change in level of consciousness. 9. Which of these medications should not be mixed with any other medication, or any IV solution other than normal saline? Phenytoin (Dilantin). 10. Which nursing intervention should the nurse include when administering the mannitol (Osmitrol)?
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