the client with head injury

7/14/2019 The Client With Head Injury

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The Client with Head Injury

1. An unconscious client with multiple injuries arrives in the emergency room. Which nursingintervention receives the highest priority?

1. Establishing an airway.2. Replacing blood loss.3. Stopping bleeding from open wounds.

4. Checking for a neck fracture.

The highest priority for a client with multiple injuries is to establish an open airway for effective ventilation and oxygenation. Unless the client has a patent airway, other caremeasures will be futile. Replacing blood loss, stopping bleeding from open wounds, andchecking for a neck fracture are important nursing interventions to be completed after the airway and ventilation are established.

2. A client is at risk for increased intracranial pressure (ICP). Which of the following would bethe priority for the nurse to monitor?

1. Unequal pupil size.

2. Decreasing systolic blood pressure3. Tachycardia.4. Decreasing body temperature.

Increasing ICP causes unequal pupils as a result of pressure on the third cranial nerve.Increasing ICP causes an increase in the systolic pressure, which reflects the additionalpressure needed to perfuse the brain. It increases the pressure on the vagus nerve,which produces bradycardia, and it causes an increase in body temperature fromhypothalamic damage.

3. What should the nurse do first when a client with a head injury begins to have clear

drainage from his nose?1. Compress the nares.2. Tilt the head back.3. Give the client a white pad to collect the fluid.4. Administer an antihistamine for postnasal drip.

The clear drainage must be analyzed to determine whether it is nasal drainage or cerebrospinal fluid (CSF). The nurse would not place tissues at the bedside because it isimportant to know how much leakage of CSF is occurring. Compressing the nares willobstruct the drainage flow. It is inappropriate to tilt the head back, which would allow thefluid to drain down the throat and not be collected for a sample. It is inappropriate to

administer an antihistamine because the drainage may not be from postnasal drip.

4. Which of the following respiratory patterns indicate increasing ICP in the brain stem?1. Slow, irregular respirations.2. Rapid, shallow respirations.3. Asymmetric chest excursion.4. Nasal flaring.



Neural control of respiration takes place in the brain stem. Deterioration and pressureproduce irregular respiratory patterns. Rapid, shallow respirations, asymmetric chestmovements, and nasal flaring are more characteristic of respiratory distress or hypoxia.

5. Which of the following nursing interventions is appropriate for a client with an ICP of 20 mm

Hg?1. Give the client a warming blanket.2. Administer low-dose barbiturates.3. Encourage the client to hyperventilate.4. Restrict fluids.

Normal ICP is 15 mm Hg or less for 15 to 30 seconds or longer. Hyperventilation causesvasoconstriction, which reduces CSF and blood volume, two important factors for reducing a sustained ICP of 20 mm Hg. A cooling blanket is used to control the elevationof temperature because a fever increases the metabolic rate, which in turn increasesICP. High doses of barbiturates may be used to reduce the increased cellular metabolic

demands. Fluid volume and inotropic drugs are used to maintain cerebral perfusion bysupporting the cardiac output and keeping the cerebral perfusion pressure greater than80 mm Hg.

6. client has signs of increased ICP. Which of the following is an early indicator of deteriorationin the client's condition?

1. Widening pulse pressure.2. Decrease in the pulse rate.3. Dilated, fixed pupil.4. Decrease in level of consciousness.

A decrease in the client's level of consciousness is an early indicator of deterioration of the client's neurologic status. Changes in level of consciousness, such as restlessnessand irritability, may be subtle. Widening of the pulse pressure, decrease in the pulserate, and dilated, fixed pupils occur later if the increased ICP is not treated.

7. A nurse obtains a specimen of clear nasal drainage from a client with a head injury. Whichof the following tests differentiates mucus from cerebrospinal fluid (CSF)?

1. pH.2. Specific gravity.3. Glucose.4. Microorganisms.

The constituents of CSF are similar to those of blood plasma. An examination for glucose content is done to determine whether body fluid is mucus or CSF. CSF containsglucose; mucus does not.

8. The client has a sustained ICP of 20 mm Hg. Which client position would be mostappropriate?

1. The head of the bed elevated 30 to 45 degrees.2. Trendelenburg's position.3. Left Simm's position.4. The head elevated on two pillows.



The client's ICP is elevated, and the client should be positioned to avoid extreme neckflexion or extension. The head of the bed is usually elevated 30 to 45 degrees to drainthe venous sinuses and thus decrease the ICP. Trendelenburg's position places theclient's head lower than the body, which would increase ICP. The Simm's position (sidelying) and elevating the head on two pillows may extend or flex the neck, whichincreases ICP.

9. The nurse administers mannitol (Osmitrol) to the client with increased ICP. Which parameter requires close monitoring?1. Muscle relaxation.2. Intake and output.3. Widening of the pulse pressure.4. Pupil dilation.

After administering mannitol (Osmitrol), the nurse closely monitors intake and output,because mannitol promotes diuresis and is given primarily to pull water from theextracellular fluid of the edematous brain. Mannitol can cause hypokalemia and maylead to muscle contractions, not muscle relaxation. Signs such as widening of the pulse

pressure and pupil dilation should not occur, because the mannitol serves to decreaseICP.

10.A male client with a head injury regains consciousness after several days. Which of thefollowing nursing statements is most appropriate as the client awakens?

1. "I'll get your family."2. "Can you tell me your name and where you live?"3. "I'll bet you're a little confused right now."4. "You are in the hospital. You were in an accident and unconscious."

It is important to first explain where a client is to orient him to time, person, and place.Offering to get his family and asking him questions to determine whether he is orientedare important, but the first comments should let the client know where he is and whathappened to him. It is useful to be empathetic to the client, but making a comment suchas "I'll bet you're a little confused" when he first awakens is not helpful and may causehim anxiety.

11.A client who is regaining consciousness after a craniotomy becomes restless and attemptsto pull out her intravenous line. Which nursing intervention protects the client withoutincreasing her ICP?

1. Place her in a jacket restraint.2. Wrap her hands in soft "mitten" restraints.3. Tuck her arms and hands under the draw sheet.4. Apply a wrist restraint to each arm.

It is best for the client to wear mitts which help prevent the client from pulling on the IVwithout causing additional agitation. Using a jacket or wrist restraint or tucking theclient's arms and hands under the drawsheet restrict movement and add to feelings of being confined, all of which would increase her agitation and increase ICP.

12.Which activity would the nurse encourage the client to avoid when there is a risk for increased ICP?

1. Deep breathing.



2. Turning.3. Coughing.4. Passive range-of-motion exercises.

Coughing is contraindicated for a client at risk for increased ICP because coughingincreases ICP. Deep breathing can be continued. Turning and passive range-of-motionexercises can be continued with care not to extend or flex the neck.

13.Which of the following is most effective in assessing the client suspected of developingdiabetes insipidus?

1. Taking vital signs every 2 hours.2. Measuring urine output hourly.3. Assessing arterial blood gas values every other day.4. Checking blood glucose.

Diabetes insipidus results from deficiency of antidiuretic hormone (ADH). The conditionmay occur in conjunction with head injuries as well as with other disorders. In ADHdeficiency, the client is extremely thirsty and excretes large amounts of highly diluted

urine. Measuring the urine output to detect excess amount and checking the specificgravity of urine samples to determine urine concentration are appropriate measures todetermine the onset of diabetes insipidus. The patient may be tachycardic andhypotensive from fluid deficit; however, altered vital signs in a patient with a head injurymay occur for other reasons as well. Blood gas analysis and blood glucose levels will notreveal diabetes insipidus.

14.A client who had a serious head injury with increased ICP is to be discharged to arehabilitation facility. Which of the following rehabilitation outcomes would be appropriate for the client?

1. The client will exhibit no further episodes of short-term memory loss.2. The client will be able to return to his construction job in 3 weeks.3. The client will actively participate in the rehabilitation process as appropriate.4. The client will be emotionally stable and display pre-injury personality traits.

Recovery from a serious head injury is a long-term process that may continue for months or years. Depending on the extent of the injury, clients who are transferred torehabilitation facilities most likely will continue to exhibit cognitive and mobilityimpairments as well as behavior and personality changes. The client would be expectedto participate in the rehabilitation efforts to the extent he is capable. Family membersand significant others will need long-term support to help them cope with the changesthat have occurred in the client.

15.Which of the following describes decerebrate posturing?1. Internal rotation and adduction of arms with flexion of elbows, wrists, and fingers.2. Back hunched over, rigid flexion of all four extremities with supination of arms and

plantar flexion of feet.3. Supination of arms, dorsiflexion of the feet.4. Back arched, rigid extension of all four extremities.

Decerebrate posturing occurs in patients with damage to the upper brain stem, midbrain,or pons and is demonstrated clinically by arching of the back, rigid extension of theextremities, pronation of the arms, and plantar flexion of the feet. Internal rotation and



adduction of arms with flexion of elbows, wrists, and fingers describes decorticateposturing, which indicates damage to corticospinal tracts and cerebral hemispheres.

16.client receiving vent-assisted mode ventilation begins to experience cluster breathing after recent intracranial occipital bleeding. Which action would be most appropriate?

1. Count the rate to be sure that ventilations are deep enough to be sufficient.2. Call the physician while another nurse checks the vital signs and ascertains

the patient's Glasgow Coma Scale score.3. Call the physician to adjust the ventilator settings.4. Check deep tendon reflexes to determine the best motor response.

Cluster breathing consists of clusters of irregular breaths followed by periods of apneaon an irregular basis. A lesion in the upper medulla or lower pons is usually the cause of cluster breathing. Because the client had a bleed in the occipital lobe, which is justsuperior and posterior to the pons and medulla, clinical manifestations that indicate anew lesion are monitored very closely in case another bleed ensues. The physician isnotified immediately so that treatment can begin before respirations cease. Another nurse needs to assess vital signs and score the client according to the Glasgow Coma

Scale, but time is also of the essence. Checking deep tendon reflexes is one part of theGlasgow Coma Scale analysis.

17.In planning the care for a client who has had a posterior fossa (infratentorial) craniotomy,which of the following is contraindicated when positioning the client?

1. Keeping the client flat on one side or the other.2. Elevating the head of the bed to 30 degrees.3. Log rolling or turning as a unit when turning.4. Keeping the neck in a neutral position.

Elevating the head of the bed to 30 degrees is contraindicated for infratentorialcraniotomies because it could cause herniation of the brain down onto the brain stemand spinal cord, resulting in sudden death. Elevation of the head of the bed to 30degrees with the head turned to the side opposite the incision, if not contraindicated bythe ICP, is used for supratentorial craniotomies.

the client with head injury

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