HESI CASE STUDIES--MEDICAL/SURGICAL-
TRAUMATIC BRAIN INJURY (JEFF
DICKSON)
1. Which assessment techniques are used to determine physiological
manifestations of a traumatic brain injury? (Select all)
-Assess the equality of Jeff's pupils
-Observe the area behind Jeff's ears
-Observe the area around Jeff's eyes
-Check Jeff's nasal cavity for leaking fluid
2. What methods can the nurse use to determine if the
drainage is CSF? Observe for a "halo" around a spot of
drainage.
3. Which nursing intervention should be initiated to prevent increased
intracranial pressure (ICP)?
Administer a prescribed stool softener as needed (PRN).
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. What are the three components measured by
the GCS? Verbal response, motor response, and
eye opening.
6. What is the Glascow Coma Scale rating obtained in this
assessment. 10
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. What is the most important indicator of
increasing ICP? Change in level of consciousness.
9. Which of these medications should not be mixed with any other
medication, or any IV solution other than normal saline?
Phenytoin (Dilantin).
TRAUMATIC BRAIN INJURY (JEFF
DICKSON)
1. Which assessment techniques are used to determine physiological
manifestations of a traumatic brain injury? (Select all)
-Assess the equality of Jeff's pupils
-Observe the area behind Jeff's ears
-Observe the area around Jeff's eyes
-Check Jeff's nasal cavity for leaking fluid
2. What methods can the nurse use to determine if the
drainage is CSF? Observe for a "halo" around a spot of
drainage.
3. Which nursing intervention should be initiated to prevent increased
intracranial pressure (ICP)?
Administer a prescribed stool softener as needed (PRN).
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. What are the three components measured by
the GCS? Verbal response, motor response, and
eye opening.
6. What is the Glascow Coma Scale rating obtained in this
assessment. 10
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. What is the most important indicator of
increasing ICP? Change in level of consciousness.
9. Which of these medications should not be mixed with any other
medication, or any IV solution other than normal saline?
Phenytoin (Dilantin).
