HESI Case Studies--Medical/Surgical-Traumatic Brain Injury (Jeff Dickson) questions with correct answers

1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all) CORRECT ANSWER -Assess for tinnitus or hearing difficulty - observe the area behind his ears - observe the area round his eyes - check his ear cavity for leaking fluid 2. What methods can the nurse use to determine if the drainage is CSF? CORRECT ANSWER Observe for a "halo" around a spot of drainage. 3. Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)? CORRECT ANSWER Elevate HOB 4. Jeff requests "something for his headache." Which medication is best for the nurse to administer to Jeff for his complaint of headache? CORRECT ANSWER Acetaminophen (Tylenol). 5. What are the three components measured by the GCS? CORRECT ANSWER Verbal response, motor response, and eye opening. 6. What is the Glascow Coma Scale rating obtained in this assessment. CORRECT ANSWER 11 7. About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse? CORRECT ANSWER Diminished neurologic status.