HESI Case Studies--Medical/Surgical-Traumatic Brain Injury (Jeff Dicks
EXAM 2022\2023
1. 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. 2. What methods can the nurse use to determine if the drainage is CSF?:
Observe for a "halo" around a spot of drainage.
3. 3. Which nursing intervention should be initiated to prevent increased
intracranial pressure (ICP)?: Elevate HOB
, 4. 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. 5. What are the three components measured by the GCS?: Verbal
response, motor response, and eye opening.
6. 6. What is the Glascow Coma Scale rating obtained in this assessment.:
11
7. 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. 8. What is the most important indicator of increasing ICP?: Change in
level of consciousness.
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