J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbour got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbour drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.
Identify at least six findings that would indicate this complication is occurring

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

You complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation intact. J.R. complains of a headache and is somewhat drowsy. His vital signs are 120/72, 114, 30, $98.7^{\circ} \mathrm{F}\left(37.1^{\circ} \mathrm{C}\right)$, and $\mathrm{Spo}_2 94 \%$. As the radiology technician performs a portable cross-table lateral cervical spine $x$-ray examination, J.R. begins to speak incoherently and appears to drift off to sleep.

While waiting for the provider to arrive, J.R. becomes unresponsive to verbal stimuli. The right pupil is larger than the left and does not respond to light. J.R. responds to painful stimuli in the manner shown in the illustration. What immediate actions will you take?

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

You find that J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupil is larger than the left and does not respond to light.

You summon the physician. Based on the GCS score, what are the next steps you will take?

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbour got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbour drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.
What steps will you take to assess J.R.?

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

While he is in surgery, J.R.'s family arrives at the ED with their faith healer. They ask that their faith healer anoint J.R. and pray over him. What should the nurse say?

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

The physician orders a $25\%$ mannitol solution IV. What is mannitol, and why is it being administered to J.R.?

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

J.R. has ICP monitoring in place with an intraventricular catheter. Nursing interventions related to J.R.'s care while the catheter is in place include: (Select all that apply.)

• a. continuously monitoring the ICP waveforms.
• b. using aseptic technique when setting up the device.
• c. maintaining a cerebral perfusion pressure of $60$ mm Hg.
• d. leveling the transducer even with the foramen of Monroe.
• e. administering prophylactic antibiotic therapy.
• f. notifying the physician if the ICP is greater than $30$ mm Hg.

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

What is a normal intracranial pressure (ICP), and why is increased ICP so clinically important?

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

You find that J.R. has become unresponsive to verbal stimuli and responds to painful stimuli by abnormally flexing his extremities (decorticate movement). He has no verbal response. The right pupil is larger than the left and does not respond to light.

What is J.R.'s GCS score at this time? Indicate what this means.

J.R. is a $28$-year-old man who was doing home repairs. He fell from the top of a $6$-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

Identify at least five signs and symptoms of increased ICP.

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room. Differentiate between primary and secondary head injuries.

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.

You complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation intact. J.R. complains of a headache and is somewhat drowsy. His vital signs are 120/72, 114, 30, $98.7^{\circ} \mathrm{F}\left(37.1^{\circ} \mathrm{C}\right)$, and $\mathrm{Spo}_2 94 \%$. As the radiology technician performs a portable cross-table lateral cervical spine $x$-ray examination, J.R. begins to speak incoherently and appears to drift off to sleep. What are the next actions you will take?

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbour got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbour drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.
What complication common to each of these diagnoses concerns you most?

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. The neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room. List at least 6 components of a neurologic examination.