1
EVOLVE CASE STUDY WEEK 7 ADULT-
NEUROLOGICAL {ALREADY GRADED
A+ } NEWEST VERSION
You work in an Intensive Care Unit (ICU) in a large medical center. Jim Brown, 29 years old,
has a traumatic brain injury. He is being transferred to the ICU from the Emergency
Department (ED). Jim, who works for a roofing company, fell off a roof (estimated height 25
feet). He was found alert, lying on his left side. He reportedly had lost consciousness for
about five minutes. You receive a telephone report of Jim's status as he is transported to
the Intensive Care Unit (ICU). You care for many patients with traumatic brain injury.
Assessment for neurologic deterioration is critical.
Question 1: The best indicator of deterioration in a patient with traumatic brain injury is
change in:
A. breathing pattern
B. heart rhythm
C. skin color
D. blood pressure
E. level of consciousness
Correct Answer: E. level of consciousness
Explanation: Decreasing level of consciousness is the best indicator of neurological
deterioration. Level of consciousness, or arousability, is a state of awakeness and ability to
interact with the environment. Level of consciousness is optimal when cerebral
metabolism and cerebral blood flow are normal. When cerebral metabolism or cerebral
blood flow are not normal, neurological deterioration occurs, and level of consciousness
decreases.
Context: The Glasgow Coma Scale (GCS) is one source of data regarding level of
consciousness. Use of the Glasgow Coma Scale (GCS) allows for standardized
neurological assessment and reporting of arousal and awareness. Serial assessments
allow for identification of subtle changes over time. As you prepare to receive Jim in the
Intensive care Unit (ICU), you anticipate his appearance and abilities.
, 2
Question 2: With a Glasgow Coma Scale (GCS) score of 15, you expect Jim to be: (Select
all that apply)
A. slightly confused
B. alert and oriented
C. able to open his eyes spontaneously
D. unresponsive to pain
E. incomprehensible
F. responsive only to pain
G. able to obey commands
Correct Answers: * B. alert and oriented (Score of 15 is the best possible score. You
would expect Jim to be alert and oriented to person, place, and time.)
• C. able to open his eyes spontaneously * G. able to obey commands (You would
expect Jim to be able to obey commands and move appropriately in response to
verbal requests.)
Context: The Glasgow Coma Scale (GCS) should be used in conjunction with other
neurological examinations. Many patients with a GCS score of 15 have serious brain
damage requiring intervention. Ongoing thorough assessment of Jim is critical. You admit
Jim to the ICU. He is alert but uncomfortable, and complaining of a headache. Jim has a
basilar skull fracture with a small subdural hematoma on the left side.
Question 3: As you assess Jim, you recall that the pathophysiology of subdural hematoma
involves:
A. collection of blood between the dura mater and arachnoid mater
B. collection of blood between the dura mater and the skull
Correct Answer: A. collection of blood between the dura mater and arachnoid mater
Explanation: A subdural hematoma is a collection of blood in the subdural space, which is
between the dura mater and the arachnoid mater.
, 3
Context: Secondary brain injury, a result of a variety of physiological responses to the
primary injury, may further damage the brain. Responses include brain ischemia, cerebral
edema, hypercapnia, hypertension, and hypotension. Measures to avoid increases in
intracranial pressure (ICP) are critical. Because Jim could have a spinal fracture as a result
of his fall, his spine is immobilized.
Question 4: You know that spine immobilization cannot be removed until:
A. 48 hours have passed
B. Jim's neurological status has stabilized
C. Jim is ready for discharge from the Intensive Care Unit (ICU)
D. injury to the spine has been ruled out
Correct Answer: D. injury to the spine has been ruled out
Explanation: Spine immobilization and alignment must be maintained until there is
radiological proof (usually three-view spinal x-ray and/or CT scan) that all vertebrae are
negative for injury.
Context: The physician has entered orders for Jim. The prescribed Osmitrol (mannitol) and
Lasix (furosemide) were given in the Emergency Department (ED).
Question 5: The drug literature indicates that Dilantin (phenytoin) be administered at a
bolus IV rate not exceeding 50 mg per minute. 750 mg is ordered. You determine that the
drug should be administered:
A. over 5 minutes
B. over 10 minutes
C. over 15 minutes
Correct Answer: C. over 15 minutes
Explanation: 750 mg of Dilantin should infuse over at least 15 minutes ( = 15).
Question 6: You prepare to administer the Dilantin (phenytoin) piggy-backed through a Y-
tube IV infusion set. The primary IV is a solution of Lactated Ringer's. Before infusing the
Dilantin (phenytoin), you:
EVOLVE CASE STUDY WEEK 7 ADULT-
NEUROLOGICAL {ALREADY GRADED
A+ } NEWEST VERSION
You work in an Intensive Care Unit (ICU) in a large medical center. Jim Brown, 29 years old,
has a traumatic brain injury. He is being transferred to the ICU from the Emergency
Department (ED). Jim, who works for a roofing company, fell off a roof (estimated height 25
feet). He was found alert, lying on his left side. He reportedly had lost consciousness for
about five minutes. You receive a telephone report of Jim's status as he is transported to
the Intensive Care Unit (ICU). You care for many patients with traumatic brain injury.
Assessment for neurologic deterioration is critical.
Question 1: The best indicator of deterioration in a patient with traumatic brain injury is
change in:
A. breathing pattern
B. heart rhythm
C. skin color
D. blood pressure
E. level of consciousness
Correct Answer: E. level of consciousness
Explanation: Decreasing level of consciousness is the best indicator of neurological
deterioration. Level of consciousness, or arousability, is a state of awakeness and ability to
interact with the environment. Level of consciousness is optimal when cerebral
metabolism and cerebral blood flow are normal. When cerebral metabolism or cerebral
blood flow are not normal, neurological deterioration occurs, and level of consciousness
decreases.
Context: The Glasgow Coma Scale (GCS) is one source of data regarding level of
consciousness. Use of the Glasgow Coma Scale (GCS) allows for standardized
neurological assessment and reporting of arousal and awareness. Serial assessments
allow for identification of subtle changes over time. As you prepare to receive Jim in the
Intensive care Unit (ICU), you anticipate his appearance and abilities.
, 2
Question 2: With a Glasgow Coma Scale (GCS) score of 15, you expect Jim to be: (Select
all that apply)
A. slightly confused
B. alert and oriented
C. able to open his eyes spontaneously
D. unresponsive to pain
E. incomprehensible
F. responsive only to pain
G. able to obey commands
Correct Answers: * B. alert and oriented (Score of 15 is the best possible score. You
would expect Jim to be alert and oriented to person, place, and time.)
• C. able to open his eyes spontaneously * G. able to obey commands (You would
expect Jim to be able to obey commands and move appropriately in response to
verbal requests.)
Context: The Glasgow Coma Scale (GCS) should be used in conjunction with other
neurological examinations. Many patients with a GCS score of 15 have serious brain
damage requiring intervention. Ongoing thorough assessment of Jim is critical. You admit
Jim to the ICU. He is alert but uncomfortable, and complaining of a headache. Jim has a
basilar skull fracture with a small subdural hematoma on the left side.
Question 3: As you assess Jim, you recall that the pathophysiology of subdural hematoma
involves:
A. collection of blood between the dura mater and arachnoid mater
B. collection of blood between the dura mater and the skull
Correct Answer: A. collection of blood between the dura mater and arachnoid mater
Explanation: A subdural hematoma is a collection of blood in the subdural space, which is
between the dura mater and the arachnoid mater.
, 3
Context: Secondary brain injury, a result of a variety of physiological responses to the
primary injury, may further damage the brain. Responses include brain ischemia, cerebral
edema, hypercapnia, hypertension, and hypotension. Measures to avoid increases in
intracranial pressure (ICP) are critical. Because Jim could have a spinal fracture as a result
of his fall, his spine is immobilized.
Question 4: You know that spine immobilization cannot be removed until:
A. 48 hours have passed
B. Jim's neurological status has stabilized
C. Jim is ready for discharge from the Intensive Care Unit (ICU)
D. injury to the spine has been ruled out
Correct Answer: D. injury to the spine has been ruled out
Explanation: Spine immobilization and alignment must be maintained until there is
radiological proof (usually three-view spinal x-ray and/or CT scan) that all vertebrae are
negative for injury.
Context: The physician has entered orders for Jim. The prescribed Osmitrol (mannitol) and
Lasix (furosemide) were given in the Emergency Department (ED).
Question 5: The drug literature indicates that Dilantin (phenytoin) be administered at a
bolus IV rate not exceeding 50 mg per minute. 750 mg is ordered. You determine that the
drug should be administered:
A. over 5 minutes
B. over 10 minutes
C. over 15 minutes
Correct Answer: C. over 15 minutes
Explanation: 750 mg of Dilantin should infuse over at least 15 minutes ( = 15).
Question 6: You prepare to administer the Dilantin (phenytoin) piggy-backed through a Y-
tube IV infusion set. The primary IV is a solution of Lactated Ringer's. Before infusing the
Dilantin (phenytoin), you:
