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Final Exam: NR574/ NR 574 (2023/2024 New Update) Acute Care Practicum Review | Week 5-8 | Questions and Verified Answers| 100% Correct- Chamberlain €11,72
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Final Exam : NR574/ NR 574 (2023/2024 New Update) Acute Care Practicum Review | Week 5-8 | Questions and Verified A nswers | 100% Correct - Chamberlain QUESTION TBI (traumatic brain injury) clinical findings Answer: headache dizziness fatigue memory loss confusion difficulty concentrating nausea and/or vomiting drowsiness, stupor, coma blurred or double vision seizure coma irregular or dilated pupils cranial nerve palsy speech impairment motor weakness or paralysis QUESTION Types of Traumatic Brain Injury Answer: -Traumatic: damage acquired from an exter - nal force -Non-traumatic -Congenital: damage or malformation in the brain that occurs before birth QUESTION Causes of Traumatic Brain Injury Answer: falls assaults sports injuries motor vehicle accidents abuse (shaken baby syndrome, domestic violence) gunshot wounds workplace injuries QUESTION causes of TBI, nontraumatic Answer: stroke (embolic, hemorrhagic, ischemic) meningitis encephalitis seizure electrical shock tumors metabolic disorders hypoxia neurotoxic substances QUESTION causes of congenital TBI Answer: cerebral palsy anencephaly encephalocele Chiari malformations congenital hydrocephalus microcephaly QUESTION Cushing's triad Answer: three classic signs —bradycardia, hypertension, and bradyp - nea—seen with pressure on the medulla as a result of brain stem herniation QUESTION objective findings of intracranial HTN Answer: -changes in the level of consciousness -Cushing's triad (suggestive of brainstem compression) bradycardia hypertension altered respiratory pattern -headache (continuous that worsens in the morning) -seizures -changes in speech -papilledema or pupillary changes -oculomotor palsies -decreased motor function decerebrate (extensor) posturing indicates more serious damage decorticate(flexor) posturing projectile vomiting (not preceded by nausea) QUESTION Decorticate posturing Answer: -"flexor posturing" or "mummy baby" (thi mummy preservation) -adduction of arms (arms fold to chest); flexion of elbows and wrists QUESTION Decerebrate posturing Answer: -"extensor posturing"; -abduction of arms, elbow and wrist extension QUESTION A concussion is considered a . Answer: mild traumatic brain injury (MTBI) QUESTION deciding factor for TBI intubation (clinical pearl) Answer: Clinical Tip: Remember "less than 8, intubate!" when evaluating a client with TBI. QUESTION Most concussions result in a loss of consciousness. True False Answer: False Rationale: The answer is false. Clients may report brief loss of consciousness follow - ing the incident but typically awaken spontaneously within a few minutes. Of note, more than 90% of clients diagnosed with a concussion do not lose consciousness at the time of injury. QUESTION Nigel is brought to the emergency department by EMS. He was riding a bicycle without a helmet and was struck by a car at a low rate of speed while crossing an intersection. His initial GCS was 14 upon arrival. EMS reports, according to witnesses at the sce ne, that Nigel sustained a brief loss of consciousness of < 5 minutes (min). He has a large hematoma to the frontal scalp and multiple skin abrasions to his extremities. A non -contrast CT of the head was normal and Nigel's follow -up GCS improved to 15.Clas sify Nigel's TBI as mild, moderate, or severe. Nigel's TBI is . Answer: Rationale: Nigel's TBI is mild. The initial GCS for clients with mild TBI is usually between 13 -
15.Radiographic imaging of the brain with CT or MRI will be normal. QUESTION Which of the following findings would the nurse practitioner (NP) expect to observe in Nigel? Select all that apply. headache dizziness retrograde amnesia nausea/vomiting drowsiness irritability seizure fixed and dilated pupils clear rhinorrhea Battle's sign or raccoon eyes Answer: Rationale: Headache, dizziness, retrograde amne - sia, nausea/vomiting, drowsiness, anxiety, irritability, labile mood, sleeping more or less than usual with a normal head CT are characteristic of mild TBI. Nigel may have had a brief initial LOC, although one is not required
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