Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury?

1. Assess for tinnitus or hearing difficulty.
2. Observe the area behind Jeff's ears.
3. Observe the area around Jeff's eyes.
4. Test Jeff's ability to follow complex directions.
5. Check Jeff’s ear cavity for leaking fluid.

A. Assess for tinnitus or hearing difficulty.

B. Observe the area behind Jeff's ears.

C. Observe the area around Jeff's eyes.

E. Check Jeff’s ear cavity for leaking fluid.

What method can the nurse use to determine if the drainage is CSF?

1. Test the fluid for glucose.
2. Observe for blood in the drainage.
3. Observe for a "halo" around a spot of drainage.
4. Note the amount of the drainage.

C. Observe for a "halo" around a spot of drainage.

Which nursing intervention should be initiated to prevent increased ICP?

1. Keep neck flexed.
2. Keep the head of the bed elevated at 30 degrees.
3. Perform passive range of motion on extremities.
4. Suction airway as needed for at least 15 seconds each time.

B. Keep the head of the bed elevated at 30 degrees.

Jeff requests something for his headache. Which medication is best for the nurse to administer to Jeff for his complaint of headache?

1. Morphine sulfate.
2. Oxycodone/aspirin (Percodan).
3. Hydrocodone/acetaminophen (Lortab).
4. Acetaminophen (Tylenol).

D. Acetaminophen (Tylenol).

Which components are measured by the GCS?

1. Verbal response, motor response, and eye opening.
2. Seizure activity, muscle strength, and range of motion.
3. Gag reflex, Patellar reflex, and Babinski reflex.
4. Pupillary response, visual field, and visual acuity.

A. Verbal response, motor response, and eye opening.

What is the Glasgow Coma Scale rating obtained in this assessment? (Enter numerical value only.)

• eyes open in response to verbal stimuli
• oriented to person only
• pulls his arm away and moves his arm in response to a needle prick.

11

This score indicates which finding to the nurse?

1. Resolving neurologic condition.
2. Declining neurologic condition.
3. Loss of consciousness.
4. Poor chance of recovery.

B. Declining neurologic condition.

Which sign is the most important early indicator of increasing ICP?

1. Changes in extraocular eye movement.
2. Changes in vital signs.
3. Change in level of consciousness.
4. Vomiting.

C. Change in level of consciousness.

The HCP prescribes the following for Jeff: 0.9 Normal Saline at 30 mL/hour. 20% mannitol IVPB every 12 hours. Furosemide 20 mg IVP following mannitol (Osmitrol). Dexamethasone 4 mg IVP every 6 hours. Phenytoin 100 mg IVP every 8 hours. Which medications can be mixed with the other medications?

1. Mannitol
2. Furosemide
3. Dexamethasone
4. Phenytoin

A. Mannitol

B. Furosemide

C. Dexamethasone

Which nursing intervention should the nurse include when administering the mannitol?

1. Monitor hematocrit and hemoglobin levels.
2. Titrate administration rate to produce a urine output of 20 mL/hr.
3. Administer by IV infusion undiluted.
4. Administer via a central line.

C. Administer by IV infusion undiluted.

This method of administration is chosen to reduce the risk of which possible problem?

1. Medication error.
2. Allergic reaction.
3. Extravasation.
4. Fluid overload.

D. Fluid overload.

The nurse prepares to administer Furosemide (Lasix) 20 mg IVP. The drug availability is Lasix 10 mg/mL. How many mL should the nurse administer IVP?

2 mL

Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?

1. PO₂ of 90 and PCO₂ of 50.
2. PO₂ of 97 and PCO₂ of 45.
3. PO₂ of 97 and PCO₂ of 35.
4. PO₂ of 88 and PCO₂ of 18.

C. PO₂ of 97 and PCO₂ of 35.

Which documentation indicates that the expected outcome of the mechanical ventilation was achieved?

1. Client exhibits no signs or symptoms of increased ICP.
2. Client's ABG results are within normal limits (WNL).
3. Client's electrolytes are within normal limits (WNL).
4. Client remains afebrile.

A. Client exhibits no signs or symptoms of increased ICP.

What is the best response by the nurse?

1. "Let me close the door so that we can talk privately."
2. "Anything you tell me is completely confidential."
3. "As a nurse, I must document everything that happens between us and other people have access to the information."
4. "While I can keep many things confidential, there are instances where I may have to share some information."

D. "While I can keep many things confidential, there are instances where I may have to share some information."

Before responding to the media, which information is of primary concern to the supervisor?

1. Does the reporter work for a reputable news agency?
2. Has the client signed a release of information?
3. How did the leak occur?
4. Have the nurses been reprimanded?

B. Has the client signed a release of information?

Which intervention should the nurse initiate?

1. Postpone going to Jeff’s room for one hour.
2. Instruct the UAP to leave him alone for a few hours.
3. Administer an analgesic for his headache.
4. Assess vital signs and neurological status.

D. Assess vital signs and neurological status.

Which additional clinical manifestation is often seen in bacterial meningitis?

1. Diarrhea.
2. Muscle pain.
3. Confusion.
4. Photophobia.

D. Photophobia.

Which additional nursing diagnosis is important to include when planning Jeff's care during this period?

1. Fluid volume excess.
2. Risk for impaired physical mobility.
3. Risk for constipation.
4. Ineffective coping.

B. Risk for impaired physical mobility.

Which interventions must be performed by the nurse?

1. Obtain an oxygen saturation level on a postoperative client.
2. Assess an older adult client with dyspnea.
3. Ambulate a client in the hallway.
4. Assist a client who has vomited to change the hospital gown.
5. Provide discharge instructions to a client ready to go home.

B. Assess an older adult client with dyspnea.

E. Provide discharge instructions to a client ready to go home.

Which statement about adolescents should guide the nurse's response?

1. Adolescents need to create or nurture things that will outlast them.
2. Adolescents need to form loving relationships with other people.
3. Adolescents need to develop a sense of self and personal identity.
4. Adolescents need to begin to assert control and power over their environment.

C. Adolescents need to develop a sense of self and personal identity.

What is the nurse's best response to Jeff's refusal to see his friends?

1. "Your friends may be able to help you cope better to the situation."
2. "It might be a good idea to wait a while before you visit with your friends."
3. "You sound concerned about how your friends will react when they see you."
4. "How do you think your friends will feel if you refuse to see them?"

C. "You sound concerned about how your friends will react when they see you."

Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate?

1. "I'll be as doing everything I used to do very soon."
2. "I will have to take precautions to prevent the pressure in my brain from increasing again."
3. "I may never be back to my former self."
4. "I will never be able to live on my own."

C. "I may never be back to my former self."

Which is the most significant behavior change in adolescent behavior needed to reduce traumatic brain injuries?

1. Never use an electronic device while driving.
2. Minimize distractions while driving.
3. Never get in a vehicle with someone who has been drinking alcohol.
4. Drive only during daylight hours.

C. Never get in a vehicle with someone who has been drinking alcohol.