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

Nov 7th, 2023

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24 test answers

question

1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all)

answer

-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

question

2. What methods can the nurse use to determine if the drainage is CSF?

answer

Observe for a halo around a spot of drainage.

question

3. Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)?

answer

Elevate HOB

question

4. Jeff requests something for his headache. Which medication is best for the nurse to administer to Jeff for his complaint of headache?

answer

Acetaminophen (Tylenol).

question

5. What are the three components measured by the GCS?

answer

Verbal response, motor response, and eye opening.

question

6. What is the Glascow Coma Scale rating obtained in this assessment.

answer

question

7. About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse?

answer

Diminished neurologic status.

question

8. What is the most important indicator of increasing ICP?

answer

Change in level of consciousness.

question

9. Which of these medications can be mixed with any other medication, or any IV solution other than normal saline?

answer

mannitol furosemidedexamethasone

question

10. Which nursing intervention should the nurse include when administering the mannitol (Osmitrol)?

answer

Administer by IV infusion undiluted

question

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:

answer

Fluid overload.

question

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.)

answer

question

13. Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?

answer

PO2 of 97 and PCO2 of 35

question

14. Which documentation indicates the expected outcome of the mechanical ventilation was achieved?

answer

Client exhibits no symptoms of increased ICP.

question

15. What is the best response by the nurse?

answer

While i can keep many things confidential, there are instances where i may have to share some information

question

16. What is the primary concern the supervisor should consider prior to responding to the media?

answer

Has the client authorized the release of information?

question

17. Which intervention should the nurse initiate?

answer

assess vitals and neuro status

question

18. What additional clinical manifestation is often seen in bacterial meningitis?

answer

photophobia

question

19. What additional nursing diagnosis is important to include when planning Jeff's care during this period?

answer

Risk for impaired physical mobility

question

20. Which intervention(s) must be performed by the RN? (Select all)

answer

- assess an older client with dyspneaprovide discharge instructions to a client ready to go home

question

21. Which statement about adolescents should guide the nurses response?

answer

sense of self and personal identity

question

22. What is the nurse's best response to Jeff's refusal to see his friends?

answer

You sound concerned about how your friends will react when they see you

question

23. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate?

answer

I may never be back to my former self

question

24. What is the most significant change in adolescent behavior needed to reduce traumatic brain injuries?

answer

Never get in a vehicle with someone who has been drinking alcohol

1 of 24

question

1. Which assessment techniques are used to determine physiological manifestations of a traumatic brain injury? (Select all)

answer

-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

question

2. What methods can the nurse use to determine if the drainage is CSF?

answer

Observe for a halo around a spot of drainage.

question

3. Which nursing intervention should be initiated to prevent increased intracranial pressure (ICP)?

answer

Elevate HOB

question

4. Jeff requests something for his headache. Which medication is best for the nurse to administer to Jeff for his complaint of headache?

answer

Acetaminophen (Tylenol).

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question

5. What are the three components measured by the GCS?

answer

Verbal response, motor response, and eye opening.

question

6. What is the Glascow Coma Scale rating obtained in this assessment.

answer

question

7. About an hour later, Jeff's Glascow Coma Scale rating changes from 10 to 8. What does this indicate to the nurse?

answer

Diminished neurologic status.

question

8. What is the most important indicator of increasing ICP?

answer

Change in level of consciousness.

question

9. Which of these medications can be mixed with any other medication, or any IV solution other than normal saline?

answer

mannitol furosemidedexamethasone

question

10. Which nursing intervention should the nurse include when administering the mannitol (Osmitrol)?

answer

Administer by IV infusion undiluted

question

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:

answer

Fluid overload.

question

answer

question

13. Which Arterial Blood Gas (ABG) results would be desirable for a client with increased ICP?

answer

PO2 of 97 and PCO2 of 35

question

14. Which documentation indicates the expected outcome of the mechanical ventilation was achieved?

answer

Client exhibits no symptoms of increased ICP.

question

15. What is the best response by the nurse?

answer

While i can keep many things confidential, there are instances where i may have to share some information

question

16. What is the primary concern the supervisor should consider prior to responding to the media?

answer

Has the client authorized the release of information?

question

17. Which intervention should the nurse initiate?

answer

assess vitals and neuro status

question

18. What additional clinical manifestation is often seen in bacterial meningitis?

answer

photophobia

question

19. What additional nursing diagnosis is important to include when planning Jeff's care during this period?

answer

Risk for impaired physical mobility

question

20. Which intervention(s) must be performed by the RN? (Select all)

answer

- assess an older client with dyspneaprovide discharge instructions to a client ready to go home

question

21. Which statement about adolescents should guide the nurses response?

answer

sense of self and personal identity

question

22. What is the nurse's best response to Jeff's refusal to see his friends?

answer

You sound concerned about how your friends will react when they see you

question

23. Which statement by Jeff indicates that he has a clear understanding of the course of events he can anticipate?

answer

I may never be back to my former self

question

24. What is the most significant change in adolescent behavior needed to reduce traumatic brain injuries?

answer

Never get in a vehicle with someone who has been drinking alcohol

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

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