HESI Case Studies–Medical/Surgical-Traumatic Brain Injury (Jeff Dickson)

1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all)
-Assess the equality of Jeff’s pupils
-Observe the area behind Jeff’s ears
-Observe the area around Jeff’s eyes
-Check Jeff’s nasal 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)?
Administer a prescribed stool softener as needed (PRN).
4. Jeff requests “something for his headache.” Which medication is best for the nurse to administer to Jeff for his complaint of headache?
Acetaminophen (Tylenol).
5. What are the three components measured by the GCS?
Verbal response, motor response, and eye opening.

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6. What is the Glascow Coma Scale rating obtained in this assessment.
10
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 should not be mixed with any other medication, or any IV solution other than normal saline?
Phenytoin (Dilantin).
10. Which nursing intervention should the nurse include when administering the mannitol (Osmitrol)?
Use IV tubing with a filter
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:
Fluid overload.
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.)
0.7
13. Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?
PO2 of 95 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?
“It is possible I may have to share some of what you tell me with others.”
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?
Notify the health care provider of Jeff’s symptoms.
18. What additional clinical manifestation is often seen in bacterial meningitis?
Rash
19. What additional nursing diagnosis is important to include when planning Jeff’s care during this period?
Risk for injury
20. Which intervention(s) must be performed by the RN? (Select all)
-Monitor a bleeding postoperative client who is receiving a blood transfusion
-Educate a client on the use of an incentive spirometer
21. Which statement about adolescents should guide the nurses response?
The adolescent has a strong sense of peer identity
22. What is the nurse’s best response to Jeff’s refusal to see his friends?
“You are worried about how your friends are going to react to you.”
23. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate?
“I may have some long-lasting effects from this injury.”
24. What is the most significant change in adolescent behavior needed to reduce traumatic brain injuries?
Always designate a safe driver who will not drink
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