Nursing School TBI

Which of the following terms best aligns with the description- bilateral head injury although the impact was unilateral?

• Monroe Kellie Doctrine

• Coup and countercoup

• Feedback loop

• Closed system

When a TBI occurs, a positive feedback loop commences that includes- Decreased cerebral blood flow, _____________, Increase in PCO2 which ___________ the pH, and cerebral vasodilation with edema that further increases ___________.

• Tissue hypoxia, increases, intracranial pressure

• Loss of vision, increases, intracranial pressure

• Loss of consciousness, intracranial pressure

• Tissue hypoxia, decreases, intracranial pressure

The nurse is giving bedside shift report for a Pt with a TBI. The offgoing and oncoming nurse notices which of the following that could indicate subtle changes in LOC?

• The Pt awakens from a nap and takes a moment to realize where they were

• The Pt begins nervously pulling at their wristband

• The Pt had a restless night and appeared very sleepy at 0700

• The Pt's has slurred speech that wasn't previously noted

• The Pt has decreased hand grasp strength unilaterally

Which intervention is most important for a Pt with a Glasgow coma scale of 7?

• Insertion of an indwelling foley catheter

• Intubation

• Head to toe physical assessment

• Telemetry monitoring

It is determined that the patient with a Glasgow coma of 5 will not survive the injuries sustained by a TBI. What must occur before the patient is extubated?

• Call a clergy member of the patient's faith to bedside

• Call a code to attempt life-saving measures one last time

• Call organ procurement and ask family about organ donation

• Call the legal team to ensure advance directives are followed

Which assessments are essential for the nurse to initially conduct on the TBI patient for baseline purposes? (not all inclusive)

• Pupillary responses

• Gait

• Cranial nerve

• Hand and foot strength

• LOC and the ability to follow commands

The nurse understands that if a Pt receives a 7 or less on the Glasgow coma scale then the Pt is...

• A&Ox3

• in a coma

• able to maintain airway

• able to eat small meals

The nurse assessing the Pt with a TBI sees that the arms are extended down with hands and feet flexed. The nurse knows this is an ominous sign of _____________ posturing and occurs when there is _______________ within the brain.

• decerebrate posturing, decreased CSF

• decerebrate posturing, severe hypoxia

• decorticate posturing, decreased CSF

• decorticate posturing, severe hypoxia

Decorticate posturing is one point more than Decerebrate posturing on the Glasgow coma scale

• True

• False

The blood glucose level is important to obtain for the trauma patient.

• True

• False