NURS 3350-68 management of brain trauma. Questions ,answers and Explanation

NURS 3350-68 management of brain trauma. Questions ,answers and Explanation Answer Key Question 1: (see full question) Level of consciousness (LOC) can be assessed based on criteria in the Glasgow Coma Scale (GCS). Which of the following indicators are assessed in the GCS? Select all that apply. You selected: • Verbal response • Eye opening • Motor response Correct Explanation: LOC can be assessed based on the criteria in the GCS, which include eye opening, verbal response, and motor response. The patient’s responses are rated on a scale from 3 to 15. I ... (more) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2001. Chapter 68: Management of Patients With Neurologic Trauma - Page 2001 Question 2: (see full question) A patient has been diagnosed with a concussion. He is to be released from the emergency department. The nurse teaches the family or friends who will be caring for the patient to contact the physician or return to the ED if the patient You selected: vomits. Correct Explanation: Vomiting is a sign of increasing intracranial pressure and should be reported immediately. In general, the finding of headache in the patient with a concussion is an expected abnor ... (more) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 1998. Chapter 68: Management of Patients With Neurologic Trauma - Page 1998 Question 3: (see full question) A 24-year-old female rock climber is brought to the Emergency Department after a fall from the face of a rock. The young lady is admitted for observation after being diagnosed with a contusion to the brain. The client asks the nurse what having a contusion means. How should the nurse respond? You selected: Contusions are bruising, and sometimes, hemorrhage of superficial cerebral tissue. Correct Explanation: Contusions result in bruising, and sometimes, hemorrhage of superficial cerebral tissue. When the head is struck directly, the injury to the brain is called a coup injury. Dual bru ... (more) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 1998. Chapter 68: Management of Patients With Neurologic Trauma - Page 1998 Question 4: (see full question) Which of the following is the earliest sign of increasing intracranial pressure (ICP)? You selected: Change in level of consciousness (LOC) Correct Explanation: The earliest sign of increasing ICP is a change in LOC. Any changes in LOC should be reported immediately. Seizures, restlessness, and pupil changes may occur, but these are not th ... (more) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 2004. Chapter 68: Management of Patients With Neurologic Trauma - Page 2004 Question 5: (see full question) A client with a T4-level spinal cord injury (SCI) is experiencing autonomic dysreflexia; his blood pressure is 230/110. The nurse cannot locate the cause and administers antihypertensive medication as ordered. The nurse empties the client's bladder and the symptoms abate. Now, what must the nurse watch for? You selected: Spinal shock Incorrect Correct response: Rebound hypotension Explanation: When the cause is removed and the symptoms abate, the blood pressure goes down. The antihyperstensive medication is still working. The nurse must watch for rebound hypotension. Reb ... (more) Answer Key Question 1: (see full question) While snowboarding, a 17-year-old client fell and struck his head, resulting in a loss of consciousness. Within an hour after his arrival via squad at the ED where you practice nursing, he regained consciousness. He was admitted for 24-hour observation and was discharged without neurologic impairment. What would you expect the neurologist’s diagnosis to be? You selected: Concussion Correct Explanation: 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 w ... (more) Reference: Hinkle, J.L., and Cheever, K.H. Brunner & Suddarth's Textbook of Medical-Surgical Nursing, 13th ed. Philadelphia: Lippincott Williams & Wilkins, 2014, Chapter 68: Management of Patients With Neurologic Trauma, p. 1998. Chapter 68: Management of Patients With Neurologic Trauma - Page 1998 Question 2: (see full question) A client who is disoriented and restless after sustaining a concussion during a car accident is admitted to the hospital. Which nursing diagnosis takes the highest priority in this client's care plan? You selected: Risk for injury