Cognition

Question 1

What is the difference between a primary head injury and a secondary injury?

Answer 1

A primary injury is caused by an external force (Gunshots, sharp objects, blunt objects)
A secondary head injury is caused by intracranial damage or systemic insults to the brain. (cerebral ischemia, IICP, edema, hypoxia, fever, infection, and hyponatremia)

Question 2

What is post-concussion syndrome?

Answer 2

A series of concussion-like symptoms that occur 7-10 days after a concussion

Question 3

What are the symptoms of post-concussion syndrome?

Answer 3

Nausea, headache, dizziness, fatigue, memory problems, difficulty concentrating, insomnia, light and noise sensitivity, and/or personality changes.

Question 4

What is Second Impact Syndrome?

Answer 4

Occurs when an individual receives a second concussion before the initial concussion is completely healed

Question 5

How are TBI’s classified based on the Glasgow Coma Scale?

Answer 5

13-15= Mild
9-12= moderate
3-8= severe
<3= fatal injuries

Question 6

How are TBI’s classified by time?

Answer 6

Loss of con. <30 min/amnesia<24 hours= Mild
Loss of con. >30 min and <24 hours/ >24 hours and <7 days= Moderate
Loss of con. 24 or more/amnesia >7 days= severe

Question 7

What are some of the common causes of TBI’s?

Answer 7

Falls, violence, vehicle-related collisions, explosive blasts, combat injuries, and sports (boxing, football, hockey, and skateboarding)

Question 8

What are the common risk factors for TBI’s?

Answer 8

Children <4= Falls and abuse
Adolescents/YA’s= Interpersonal violence, sports, and risky behavior
Older adults= falls related to sensory perception changes or medication side effects
People who do not use proper safety precautions in vehicles
Individuals who participate in high-impact or extreme sports
Individuals who are frequently exposed to violence
Individuals in the armed forces

Question 9

What are the 3 categories for the Glasgow Coma Scale?

Answer 9

Eye-opening, verbal response, Motor Response

Question 10

What are some physical changes associated with mild TBI’s/Concussions?

Answer 10

Possible loss of consciousness for 30 minutes or less
Nausea or vomiting
headache, fatigue

Question 11

What are some physical changes associated with moderate/severe TBI’s?

Answer 11

Loss of consciousness for a period of 30 minutes to several days or weeks
Skull fracture
Bleeding in the brain
Increased ICP
Lacerations
Seizures
Loss of coordination, muscle weakness
Paralysis
Difficulty breathing
Loss of bladder and bowel control
Dysphagia

Question 12

What are the signs of a skull fracture?

Answer 12

Bleed from facial orifices, Battle sign, Raccoon eyes, Drainage of CSF from ears or nose, and/or stiff neck

Question 13

What are the clinical therapies for Physical changes related to TBI’s?

Answer 13

Administer acetaminophen
Provide comfort measures to reduce environmental stimuli
Surgery to repair skull fractures or remove hematomas
Perform trauma responses: ensure airway, breathing, and stop circulation; stop bleeding of wounds; clean and bandage wounds; set fractured bones
Monitor ICP
Safety during seizures
Antiseizure meds
Urinary catheter as needed

Question 14

What are some visual changes associated with mild TBI’s/concussions?

Answer 14

Double or blurred vision

Sensitivity to light

Question 15

What are some visual changes associated with moderate/severe TBI’s?

Answer 15

Unequal pupils
Pupils that are not reactive to light
loss of eye movement
Problems with convergence and accommodation
Blindness

Question 16

What are the clinical therapies for visual changes related to TBI’s?`

Answer 16

Monitor neuro status
Comfort measure
Clean wounds and place an eye patch over injured eyes
Prepare the patient for surgery if needed to repair eye damage

Question 17

What are some auditory and vestibular changes associated with mild TBI’s/concussions?

Answer 17

Sensitivity to sound
Dizziness, impaired balance
Tinnitus

Question 18

What are some auditory and vestibular changes associated with moderate/severe TBI’s?

Answer 18

Transient or permanent hearing loss
Difficulty distinguishing words from background noise
Mechanical injuries to the ear structures

Question 19

What are some clinical therapies for auditory and vestibular changes related to TBI’s?

Answer 19

Monitor neuro status
Comfort/reduce stimuli
Safety when moving and walking
Info about hearing aids, ASL,, etc.

Question 20

What are some Behavioral changes related to Mild TBI’s and concussions?

Answer 20

Irritability

Question 21

What are some behavioral changes related to moderate/severe TBI’s?

Answer 21

Depression
apathy
anxiety
personality changes
agitation
Flat affect
Aggression
problems with impulse control

Question 22

What are some clinical therapies for behavioral changes related to TBI’s

Answer 22

Monitor neuro status
Provide referrals to counselors as needed
Administer meds related to behavioral and emotional changes

Question 23

What are some cognitive changes associated with Mild TBI’s/concussions?

Answer 23

Confusion
The trouble with memory or concentration
Retrograde or anterograde amnesia
Difficulty waking up

Question 24

What are some cognitive changes associated with moderate/severe TBI’s?

Answer 24

Poor judgment
Reduced attention span
Probs processing info
Prob with short-term memory
Deficits in orientation to person, place, and time
Probs with self-care

Question 25

What are some clinical therapies for Cognitive changes associated with TBI’s?

Answer 25

Neuro status
Referrals to therapists for cognitive skills
Orient Person, place, and time
Give time to think and respond to info
Teach patient and/or family regarding how to perform hygiene care

Question 26

What is a symptom of verbal and language changes with mild TBI’s/concussions?

Answer 26

Slurred speech

Question 27

What are some verbal and language changes associated with moderate/severe TBI’s?

Answer 27

Deficits in verbal and reading comprehension
Decreased ability to articulate words
Decreased knowledge about the appropriate tone of voice
Writing difficulty

Question 28

What are the clinical therapies for verbal and language changes related to TBI’s?

Answer 28

Provide referrals to speech therapists as needed
Be patient when communicating; give them time
provide writing instruments and paper

Question 29

What diagnostic tests are used with TBI’s?

Answer 29

CT and MRI scans
Measuring ICP
Transcranial Dopler for a hemorrhage
Assess for CSF if the fluid is leaking from the nose or ears

Question 30

When may surgery be needed for a TBI?

Answer 30

Evacuation of a cerebral hematoma
skull, facial, or mandibular fractures
placement of an ICP monitoring device
Removal of foreign bodies from the cranial vault

Question 31

What medications are typically used for TBI’s?

Answer 31

Vasoactive meds to keep pt hemodynamically stable
Anesthesia if going into surgery
Pain meds
Meds to reduce IICP
Antiseizure meds
H2-receptor antagonists (Pepcid)
Proton pump inhibiting agents
Stool softeners/laxatives

Question 32

What nonpharmacologic therapy is used for TBI’s?

Answer 32

Rehabilitation or therapy
Clergy, grief counseling
Speech therapy
occupational therapy
Physical therapy

Question 33

What is the list of priorities in the care of someone with a TBI?

Answer 33

1. Glasgow Coma Scale
2. Prepare pt for CT
3. Perform an accurate and complete neurological examination with all cranial nerves, spinal nerves, and reflexes
4. assess pt every 15 min, every hour, or every 2-4 hours based on condition
5. report deterioration based on Glasgow Scale to physician

Question 34

What are some nursing interventions for TBI’s?

Answer 34

1. maintain adequate O2
2. Monitor and reducing ICP
3. Treating wounds
4. Teach signs of postconcussion syndrome
5. provide emotional support

Question 35

How should a nurse prepare the pt and family for discharge following a TBI?

Answer 35

1. Give info about therapy
2. Discuss needs for home care (bathing, feeding, dressing, and ADLs)
3. Educate about light activity in the home
4. Sleep is okay but for the first 12 hours after discharge they should be woken up every 2-3 hours to look for any changes
5. Tylenol is okay but don’t use NSAIDs and Aspirin
6. If stiff neck, fluid leaking from nose or ears, chronic sleepiness, worsening headache, fever, vomiting, problems walking or talking, problems thinking, seizures, or changes in vision occur, contact doctor

Question 36

What is the difference between decorticate and decerebrate posturing?

Answer 36

Decorticate posturing is characterized by rigid flexion and is associated with lesions above the brainstem in the corticospinal tracts.
Decerebrate posturing is distinguished by rigid extension and is associated with lesions in the brain stem.

Question 37

What is the normal range for intracranial pressure for infants?

Answer 37

1.5-6 mmHg

Question 38

What is the normal range for intracranial pressure for children?

Answer 38

3-7 mmHg

Question 39

What is the normal intracranial pressure range for adults?

Answer 39

5-15 mmHg

Question 40

What does PERRL stand for?

Answer 40

Pupils, equal, round, and reactive to light

Question 41

What are the Risk Factors for IICP?

Answer 41

medications, poor nutrition, illness such as meningitis, and drug and alcohol abuse, cerebral trauma

Question 42

What are the clinical manifestations of IICP?

Answer 42

Decreased in LOC, visual disturbances, vomiting, headaches, Cushing Triad (irregular breathing, bradycardia, and widening pulse pressure), behavioral changes, impaired memory and judgment, changes in speech.

Question 43

What are the Decreased LOC manifestations of cerebral edema, head trauma, tumors, abscesses, stroke, inflammation, and hemorrhages?

Answer 43

1. Decreased LOC: Early- confusion; restlessness and lethargy; disorientation, first to time, then to place and person. Late- Comatose with no response to painful stimuli

Question 44

What are the pupillary dysfunction signs of IICP?

Answer 44

Sluggish response to light, progressing to fixed pupils; with a localized process, pupillary dysfunction first noted on the ipsilateral side

Question 45

What does having fixed pupils mean?

Answer 45

The pupils are nonreactive

Question 46

What are the oculomotor dysfunction signs of IICP?

Answer 46

Inability to move eyes upward; ptosis (drooping) of the eyelid

Question 47

What are the visual abnormality signs of IICP?

Answer 47

decreased visual acuity, blurred vision, diplopia

Question 48

What are the signs of Motor impairment in IICP?

Answer 48

1. Early: Hemiparesis or hemiplegia of the contralateral side
2. Late: Abnormal responses such as decorticate or decerebrate positioning; flaccidity

Question 49

What are the headache signs of IICP?

Answer 49

Uncommon but may occur with processes that slowly increase ICP; worse upon rising in the morning and with position changes

Question 50

What are the signs of the Cushing Triad?

Answer 50

Irregular respirations, widening pulse pressure, bradycardia

Question 51

At what position should the head of the bed be elevated to with someone who has IICP?

Answer 51

30 Degrees unless otherwise indicated

Question 52

What meds may be used to help IICP?

Answer 52

1. Diuretics (particularly osmotic diuretics)- Mannitol
2. Loop diuretics
3. Ethacrynic acid
4. Antipyretics like acetaminophen
5. Antiseizure meds
6. Antihypertensives (Beta-blockers)
7. Meds to help with GI prophylaxis
8. Fluids that are not HYPOtonic

Question 53

What are some methods of ICP Monitoring?

Answer 53

1. CPP
2. epidural probe
3. Subarachnoid bold or screw
4. Intraventricular catheter (Preferred technique)

Question 54

At what age are infants more at risk for intraventricular hemorrhage?

Answer 54

Infants born more than 10 weeks prematurely

All infants born at a gestational age earlier than 30 weeks should have a cranial ultrasound for the presence of IVH

Question 55

How often should the nurse assess and monitor IICP?

Answer 55

Every 15 min- hour as necessary

Question 56

What are the nursing interventions for IICP?

Answer 56

1. airway patency
2. adequate oxygenation and ventilation
3. positioning and moving
4. preventing infection
5. monitoring fluids and electrolytes
6. Reduce ICP by elevating HOB, keep head and neck aligned, avoid prone position, do not let them push with heels or arms to move
7. reduce environmental stimuli
8. reduce risk for infection
9. Prepare family for discharge

Question 57

What should the family and patients of someone who has IICP know for discharge?

Answer 57

1. monitor the pt for decreased LOC
2. If difficult to wake pt, call 911
3. if the pt complains of a stiff nick, severe headache, or nausea and vomiting, take the pt to the ED immediately
4. Monitor pt for seizures
5. Ask the pt to immediately report any changes in vision or motor control
6. teach the patient to follow instructions to avoid coughing, blowing the nose, straining to have a bowel movement, or performing isometric movements
7. Maintain head and neck alignment when turning in bed
8. encourage the pt and family members to reduce environmental stimuli

Question 58

The CT and other diagnostic results are negative and the patient is diagnosed with a minor head injury and contusion to the right extremity. He is discharged to home. Review the patient teaching instructions that should be given to the patient and his wife.

Answer 58

Expect the person to report a headache, nausea, or dizziness for at least 24 hours.
If these symptoms are severe or do not improve, contact the physician immediately or take the person back to the emergency department.
Severe symptoms would be a decreased level of consciousness, persistent nausea or vomiting, worsening headache, double or blurred vision, drainage from ears or nose, increased confusion, numbness/weakness in extremities, or seizures
If the person is sleeping, wake him or her every 3 to 4 hours for the first 2 days, asking his or her name, where he or she is, and the name of the caregiver.
Do not leave alone
Assess hourly until patient reaches his baseline
Avoid alcohol, sleeping pills, or pain pills
Tylenol for headaches

Question 59

The nurse is performing discharge teaching for the family and patient who has had prolonged hospitalization and rehabilitation therapy for severe craniocerebral trauma after a motorcycle accident. What elements of instruction does the nurse include? (Select all that apply.)

1. Encourage the pt to wear a helmet when riding
2. Stimulate the pt with frequent changes in the environment
3. Review seizure precautions
4. Attend follow-up appointments with therapists
5. develop a routine of activities with consistency and structure
6. Encourage the family to seek respite care if needed.

Answer 59

3,4,5,6

Question 60

The nurse is giving discharge instructions to the mother of a child who bumped her head on a table. Which statement by the mother indicates an understanding of the instructions?

1. She may have nausea or headache for the first 24 hours
2. She should gently blow her nose and I’ll observe for bleeding
3. She can run and play as she usually does
4. I should not allow her to fall asleep

Answer 60

1
Nausea and headache are not unusual symptoms for a patient that has had a mild concussion.

“I should not allow her to fall asleep.” Incorrect: She can fall asleep, but will need to be awakened to evaluate neuro status
“She should gently blow her nose and I’ll observe for bleeding.”: Incorrect: She should not blow her nose
She can run and play as she usually does.”: Incorrect: She needs to remain quiet for 24-48 hours to evaluate for further neuro issues.

Question 61

The nurse is taking a history on a teenager who was involved in a motor vehicle accident with friends. The patient has an obvious contusion of the forehead, seems confused, and is laughing loudly and yelling, “Stella! Stella!” What is the best question for the nurse to ask the patient’s friends?

1. How can we notify the family for consent for treatment?
2. Who is Stella and why is the patient calling for her?
3. Where and why did the accident occur?
4. Was the patient using drugs or alcohol prior to the accident?

Answer 61

The correct answer is: “Was the patient using drugs or alcohol prior to the accident?

It is important to establish a neurological baseline and determine if there is anything that could have altered the baseline besides the accident.

Incorrect

“Where and why did the accident occur?”: It does not matter where the accident occurred in order to treat the patient
“How can we notify the family for consent for treatment?: Important information to get, but obtain after neurological status check
“Who is Stella and why is the patient calling for her?”: Assuming there is a Stella and that the friends would know why she is calling her.

Question 62

The nurse is assessing a patient who was struck in the head several times with a bat. There is a clear fluid that appears to be leaking from the nose. What action does the nurse take?

1. Immediately report the finding to the physician and document the observation in the nursing notes
2. Place a drop of the fluid on a white absorbent background and look for a yellow halo
3. Hand the patient a tissue and ask him to gently blow the nose; observe the nasal discharge for blood clots
4. Allow the patient to wipe his nose, but no other action is needed; he has most likely been crying

Answer 62

The correct answer is: Place a drop of the fluid on a white absorbent background and look for a yellow halo.

For any type of head injury when there is fluid leaking from the nose or ear, the fluid needs to be evaluated for cerebrospinal fluid (CSF) leak. To do this you would Place a drop of the fluid on a white absorbent background and look for a yellow halo. If you see a halo, it is CSF.

Hand the patient tissue and ask him to gently blow the nose; observe the nasal discharge for blood clots. Incorrect: The patient should not blow his know, (increases Intracranial pressure)
Immediately report the finding to the physician and document the observation in the nursing notes. Incorrect: You need to evaluate what type of fluids before calling the physician.
Allow the patient to wipe his nose, but no other action is needed; he has most likely been crying. Incorrect: This is an assumption. All fluids from nose and ears need to be evaluated.

Question 63

What are some conditions or disorders that cause ICP?

Answer 63

Stroke or TIA
Tumors
Infections (meningitis, encephalitis)
Poorly controlled diabetics
Long term cardiac or respiratory disease.
ETOH, narcotic, sedative, anesthetics depress the CNS which alters LOC
aneurysm rupture and subarachnoid hemorrhage
head injury
hydrocephalus
hypertension brain hemorrhage
status epilepticus

Question 64

Which statement is true about a patient at risk for increased Increased Intracranial Pressure?

1. Areas of tenderness over the scalp indicate the presence of contre-coup injuries
2. papilledema, edema, and hyperemia of the optic disk are always signs of IICP
3. Cushing’s reflex, an early sign of increased ICP, consists of severe hypertension, widening pulse pressure, and bradycardia
4. The appearance of abnormal posturing occurs only when the patient is not positioned for comfort

Answer 64

The correct answer is: Papilledema, edema, and hyperemia of the optic disk are always signs of increased ICP.

The appearance of abnormal posturing occurs only when the patient is not positioned for comfort: Incorrect: Decorticate or Decerebrate posturing occurs when there is further damage or injury to the brain resulting from increased intracranial pressure.
Cushing’s reflex, (Cushings Triad) is a late sign of increased ICP
Areas of tenderness over the scalp does not indicate the presence of contrecoup injuries. The tenderness could be caused by another issue.

Question 65

What are some signs of impending death with IICP?

Answer 65

Signs may be subtle.
Example: With bleeding subdural hematoma.
Bleeding may occur slowly with small changes in vision, nausea etc.
Early signs of ICP include lethargy.
Condition worsening if pt.
has a headache that is worsening.
If decerebrate or decorticate posturing are present.
Blown Pupils/Fixed/pin-point pupils
Non-reactive pupils
Ovoid Pupils

Question 66

The nurse is caring for a client after a recent traumatic brain injury and development of tonic-clonic seizures. The client is receiving treatment of seizures with anti-epileptic drugs (AEDs). The nurse should perform which assessment(s) for safe administrations of AEDs? Select all that apply.

1. Obtain a family history of relatives with headaches, if applicable
2. Description of seizure activity from family member who witnessed it
3. Hepatic and metabolic profiles at baseline and subsequent levels
4. Assessment of client’s description of the aura that occurs before a seizure
5. Assessment of disturbing dreams about the accident that interrupts sleep

Answer 66

The correct answers are: Description of seizure activity from family member who witnessed it, Hepatic and metabolic profiles at baseline and subsequent levels, Assessment of client’s description of the aura that occurs before a seizure.

The nurse needs to take a family history of any seizure disorders, if applicable. Gathering information about the seizure from the family is helpful in the diagnosis of the type of seizures the client is experiencing and will help the primary care provider to determine medications to use in the treatment. AEDs are metabolized in the liver and may elevate liver enzymes, so a liver profile is needed at baseline and at regular intervals. The metabolic profile helps to determine if there are other factors that are also treatable that are increasing the probability of seizures. It is important to determine if an aura occurs because the client should recognize its presence and stop activity before a seizure occurs.

The history of headaches in the family is not related to safe administration of AEDs.
The assessment of post- traumatic stress disorder includes asking about nightmares that disturb sleep and does not relate to an assessment about seizures or safe administration of AEDs.

Question 67

When vasoactive medications are administered, the nurse must monitor vital signs at least how often?

1. 15 min
2. 30 min
3. 45 min
4. hourly

Answer 67

15 minutes

When vasoactive medications are administered, the nurse must monitor vitals frequently (at least every 15 minutes until stable, or more often is indicated).

A question to ponder: Why would we need to give a patient with Increased Intracranial Pressure vasoactive medications? What is happening to the brain?