TBI Flashcards
1
Q
A nurse is assessing a client who is admitted to the facility for observation following a closed head injury. Which of the following is the PRIORITY assessment data the nurse should collect to determine change in the client’s neurological status? A. Vitals B. Body Posture C. Level of Consciousness D. Pupils
A
Answer= C. LOC
A change in LOC can be the FIRST indication of change in client neurological status.
NOT ANSWER = D. Pupils. This is a later indication of change in neurological status due to increased ICP. A+B are also later findings.
THINK: what would I assess for first if pt came into ED. Also know what a closed head injury is. Chapter 14 ATI
2
Q
What is the priority assessment for a head injury?
A
Respiratory Status = as indicated by CHANGES IN LEVEL OF CONSCIOUSNESS.
Rationale: The brain is dependent upon oxygen to maintain function and has little reserve available if oxygen is deprived. If adequate oxygenation is denied for 3-5 minutes—>hypoxia (brain injury/death)
