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HESI CS - Traumatic Brain Injury Questions With Complete Solutions
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HESI CS - Traumatic Brain Injury Questions With Complete Solutions
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HESI CS - Traumatic Brain Injury QuestionsWith Complete Solutions
A group of adolescents has gathered at a park drinking beer. At
the end of the outing, they get into an automobile driven by one
of the teens. Before even getting out of the park, the teen driver
hits a tree and the air bags are deployed. Looking around,
everyone seems alright except the unconscious teen in the
passenger seat who was not wearing a safety belt. The group
decides to drop their friend off at the local hospital emergency
department, hoping to avoid getting in trouble for underage
drinking. Correct Answers
About an hour later, the client's Glascow Coma Scale rating
changes from 11 to 9. Correct Answers
Before responding to the media, which information is of primary
concern to the supervisor?
a. Does the reporter work for a reputable news agency?
b. Has the client signed a release of information?
c. How did the leak occur?
d. Have the nurses been reprimanded? Correct Answers B
All clients have the right to confidentiality. It is the
responsibility of the nurse to safeguard client information.
In addition to a deteriorating GCS, the client begins to exhibit
additional clinical manifestations of increasing intracranial
pressure. Increased intracranial pressure (ICP) is the leading
,cause of death from traumatic brain injury for those individuals
who survive the initial trauma and make it to the hospital.
Correct Answers
On the evening that the client is transferred to the Surgical
Nursing Unit and asks to see the nurse. The client tells the nurse
about needing to talk about something, but only if it is kept
confidential. Correct Answers
The client becomes very irritable the day after being transferred
to the Surgical Unit. The UAP reports to the nurse that the client
requests that the drapes and door be closed and the lights turned
out because of a severe headache and also requested to be left
alone Correct Answers
The client is awake and requests something for a headache.
Which medication is best for the nurse to administer?
a. Morphine sulfate.
b. Oxycodone/aspirin.
c. Hydrocodone/acetaminophen.
d. Acetaminophen. Correct Answers D
This is the best choice, because acetaminophen is a non-opioid
analgesic, and it will not cause CNS depression.
The client is medicated and reports that the headache is relieved.
The nurse continues to monitor the client's vital signs and
neurologic status is assessed using the Glasgow Coma Scale
(GCS). The nurse's assessment findings are as follows:
Client's eyes open in response to verbal stimuli.
, Client is oriented to person only.
Client pulls arm away and moves arm in response to a needle
prick. Correct Answers
The client shares with the nurse that a group of friends had a
couple of beers the night of the accident and states, that they
guess they had to learn this lesson the hard way. Later that
evening, the nurse discusses what the client has said with
another nurse. This conversation takes place in the hospital
cafeteria, where it is overheard. Since the client's family is
prominent in the community, the information about alcohol use
is leaked to the media, who call the nursing supervisor to
confirm the report. Correct Answers
The client's condition gradually improves. Isolation has been
discontinued and several friends are planning to visit. Although
the client's condition is improving, there are occasional periods
of feeling fuzzy-headed and understanding all the words in a
conversation. The client tells the nurse not to let any of the
friends come because they will see a freak who can't even think
straight anymore. Correct Answers
The client's parents accompany the client for discharge. There
are still some issues with impaired memory, occasional
emotional outbursts, and difficulty following long conversations,
which all seem to be related to traumatic brain injury. The
client's nurse is invited to discuss risk factors related to
traumatic brain injury at the local high school. Correct Answers
The CT scan reveals that the client has an acute subdural
hematoma and is taken to the Operating Room for drainage via
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