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WorksheetsNursing School TBI
Total questions: 24
Worksheet time: 14mins
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
Cushing's triad is a late sign of TBI and consists of which of the following?
Acute hypotension
Hypertension with a widening pulse pressure
Tachycardia
Irregular, shallow respirations
Bradycardia
The nurse is assessing the Pt's pupillary responses and notices fixed, dilated pupils. What does the nurse suspect?
The patient is hypoglycemic
A blood analysis would show positive halo sign
There is a subdural hematoma
Brain herniation
How do you calculate pulse pressure?
PP = SBP - DBP
PP = DBP x 2 + SBP / 3
PP = DBP / SBP
PP = SBP / DBP
A widening pulse pressure is a sign of _____________.
basilar skull fracture
herniation
bradycardia
stroke
What is the best way of measuring ICP?
Assessment of LOC
Pupillary responses
Ventriculostomy
Subdural bolt
What is the normal ICP range in adults?
1-10 mmHg
5-15 mmHg
15-25 mmHg
25-35 mmHg
Which of the following statements are true concerning ICP monitoring with a ventriculostomy?
ICP is measured upon expiration
An ICP reading of 24 is life threatening
The manometer must be midline with the top of the head
Immediate intervention is required for a measurement above 20 mmHg
Pt's BP is 100/54 with an ICP of 19. What does the calculated CPP tell you about this patient?
The patient has a strong chance of recovery
The patient will most likely die
The patient is comatose, but will most likely awaken soon
The patient will exhibit some mental status changes
The normal CPP is _______________.
5-15 mmHg
30-40 mmHg
60-100 mmHg
70-110 mmHg
Which is the main reason hyperventilation to lower CO2 is a temporary intervention?
It may cause subcutaneous emphysema
It lowers cerebral blood flow
It increases peripheral resistance
It decreases lung compliance
The nurse is administering mannitol for the Pt with increased cerebral swelling. Which of the following should the nurse assess for while the patient is taking this medication?
Hypotension
Hypertension
I's & O's
MAP and CPP
ALT and AST
Which statements are true regarding nutritional interventions post head trauma?
Increased ICP results in hyper-metabolism
There is less of a glucose demand and the Pt can become hyperglycemic easily
The Pt will receive nutrition via Dobhoff with tube feeds initially
Nutrition is started within 3 days
Keep patient hydrated.
An increase in PaCO2 causes vasodilation which ___________ ICP. Hyperventilation via mechanical vent will lower the PaCO2 leading to vasoconstriction which ___________ ICP. What complication can arise from this intervention?
decreases, increases. High CPP
increases, decreases. Decreased cerebral blood flow
decreases, increases. CSF shunting
increases, decreases. Decreased pupillary responses
Which statement is INCORRECT about Mannitol? (Taken from Nurse Sarah quiz)
Mannitol will remove water from the brain and place it in the blood to be removed from the body
Mannitol will cause water and electrolyte reabsorption in the renal tubules
When a Pt receives Mannitol the nurse must monitor the Pt for both fluid volume overload and depletion
Mannitol is not for patients who are experiencing anuria
