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HESI Case Studies--Medical/Surgical-Traumatic Brain Injury (Jeff Dickson)
Terms in this set (24)
1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all)
-Assess for tinnitus or hearing difficulty
- observe the area behind his ears
- observe the area round his eyes
- check his ear cavity for leaking fluid
2. What methods can the nurse use to determine if the drainage is CSF?
Observe for a "halo" around a spot of drainage.
3. Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)?
4. Jeff requests "something for his headache." Which medication is best for the nurse to administer to Jeff for his complaint of headache?
5. What are the three components measured by the GCS?
Verbal response, motor response, and eye opening.
6. What is the Glascow Coma Scale rating obtained in this assessment.
7. About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse?
Diminished neurologic status.
8. What is the most important indicator of increasing ICP?
Change in level of consciousness.
9. Which of these medications can be mixed with any other medication, or any IV solution other than normal saline?
10. Which nursing intervention should the nurse include when administering the mannitol (Osmitrol)?
Administer by IV infusion undiluted
11. The nurse administers the normal saline using an electronic controller and a buretrol. This method of administration is chosen to reduce the risk of:
12. The nurse prepares to administer Fuorsemide (Lasix) 20 mg IVP. The drug availability is Lasix 60 mg / 2 mL. How many mL should the nurse administer IVP? (Enter numerical value only. If rounding is necessary, round to the nearest tenth.)
13. Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?
PO2 of 97 and PCO2 of 35
14. Which documentation indicates the expected outcome of the mechanical ventilation was achieved?
Client exhibits no symptoms of increased ICP.
15. What is the best response by the nurse?
While i can keep many things confidential, there are instances where i may have to share some information
16. What is the primary concern the supervisor should consider prior to responding to the media?
Has the client authorized the release of information?
17. Which intervention should the nurse initiate?
assess vitals and neuro status
18. What additional clinical manifestation is often seen in bacterial meningitis?
19. What additional nursing diagnosis is important to include when planning Jeff's care during this period?
Risk for impaired physical mobility
20. Which intervention(s) must be performed by the RN? (Select all)
- assess an older client with dyspnea
provide discharge instructions to a client ready to go home
21. Which statement about adolescents should guide the nurses response?
sense of self and personal identity
22. What is the nurse's best response to Jeff's refusal to see his friends?
"You sound concerned about how your friends will react when they see you
23. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate?
I may never be back to my former self
24. What is the most significant change in adolescent behavior needed to reduce traumatic brain injuries?
Never get in a vehicle with someone who has been drinking alcohol
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