RNSG 2539 EXAM 3 LATEST ACTUAL EXAM
Most common times that deaths occur after a head injury - ANSWER: 1. Immediately
After
2. Within 2 hours
3. Within 3 weeks
Complications with scalp lacerations - ANSWER: - Profuse Bleeding
- Infection
Many blood vessels in the scalp. Even a small cut can cause much bleeding
Manifestations of frontal fracture - ANSWER: air in forehead tissue
CSF rhinorrhea,
pneumocranium (air between cranium and dura mater)
Manifestations of Orbital Fracture - ANSWER: Periorbital ecchymosis (raccoon eyes)
optic nerve injury
Manifestations of Temporal Fracture - ANSWER: oval-shaped bruise behind ear in
mastoid region (Battle's sign)
CSF otorrhea
middle meningeal artery disruption
epidural hematoma
Manifestations of Parietal fracture - ANSWER: Deafness
CSF or brain otorrhea
bulging of tympanic membrane caused by blood or CSF
facial paralysis
loss of taste
Battle's sign
Manifestations of Posterior fossa fracture - ANSWER: cortical blindness
visual field defects
rare appearance of ataxia or other cerebellar signs
Manifestations of Basilar skull fracture - ANSWER: CSF or brain otorrhea
bulging of tympanic membrane caused by blood or CSF
Battle's sign
tinnitus or hearing difficulty
rhinorrhea
facial paralysis
conjugate deviation of gaze
vertigo
, How to test fluids for CSF - ANSWER: 1. glucose test (unreliable if there is blood) -
Dextrostix or Tes-Tape
2. Halo sign
Nursing Interventions for Skull Fracture - ANSWER: *Basilar*
Orgosastric tube NOT NGT
- IF GCS Less than 8....INTUBATE
- Determine CSF leakage
- Eye drops/ eye patch for diplopia
- Remove patient's clothing
- Keep patient warm
- Monitor for S&S of hyperthermia
- Monitor for Infection
Diffuse Brain Injury - ANSWER: Ex. Concussion
- Injury cannot be localized to one particular area
- Pt may or may not lose total consciousness
- If loss of LOC is <5 min then sent home with HCP instructions
*Postconcussion syndrome*
- Occurs within 2 weeks to 2 months
- Lethargy, HA, personality changes, decreased memory and intellectual ability
*Diffuse Axonal Injury (DAI)*
- Widespread axonal damage after TBI
- Takes 12-24 hours or longer to develop
- decreased LOC, increased ICP, decortication or decerebration, and global cerebral
edema
- 90% of pts remain in persistant vegetative state
Focal Brain Injury - ANSWER: - Tissue damage is severe
- Surgical repair is impossible
*antibiotics (until meningitis ruled out*
unconsciousness,
*hemiplegia on the contralateral side*
*a dilated pupil on the ipsilateral side*
Contusions - ANSWER: - bruising of the brain tissue within a focal area
- usually associated with a closed head injury
- may continue to bleed and rebleed (blossom on CT scan)
Most common times that deaths occur after a head injury - ANSWER: 1. Immediately
After
2. Within 2 hours
3. Within 3 weeks
Complications with scalp lacerations - ANSWER: - Profuse Bleeding
- Infection
Many blood vessels in the scalp. Even a small cut can cause much bleeding
Manifestations of frontal fracture - ANSWER: air in forehead tissue
CSF rhinorrhea,
pneumocranium (air between cranium and dura mater)
Manifestations of Orbital Fracture - ANSWER: Periorbital ecchymosis (raccoon eyes)
optic nerve injury
Manifestations of Temporal Fracture - ANSWER: oval-shaped bruise behind ear in
mastoid region (Battle's sign)
CSF otorrhea
middle meningeal artery disruption
epidural hematoma
Manifestations of Parietal fracture - ANSWER: Deafness
CSF or brain otorrhea
bulging of tympanic membrane caused by blood or CSF
facial paralysis
loss of taste
Battle's sign
Manifestations of Posterior fossa fracture - ANSWER: cortical blindness
visual field defects
rare appearance of ataxia or other cerebellar signs
Manifestations of Basilar skull fracture - ANSWER: CSF or brain otorrhea
bulging of tympanic membrane caused by blood or CSF
Battle's sign
tinnitus or hearing difficulty
rhinorrhea
facial paralysis
conjugate deviation of gaze
vertigo
, How to test fluids for CSF - ANSWER: 1. glucose test (unreliable if there is blood) -
Dextrostix or Tes-Tape
2. Halo sign
Nursing Interventions for Skull Fracture - ANSWER: *Basilar*
Orgosastric tube NOT NGT
- IF GCS Less than 8....INTUBATE
- Determine CSF leakage
- Eye drops/ eye patch for diplopia
- Remove patient's clothing
- Keep patient warm
- Monitor for S&S of hyperthermia
- Monitor for Infection
Diffuse Brain Injury - ANSWER: Ex. Concussion
- Injury cannot be localized to one particular area
- Pt may or may not lose total consciousness
- If loss of LOC is <5 min then sent home with HCP instructions
*Postconcussion syndrome*
- Occurs within 2 weeks to 2 months
- Lethargy, HA, personality changes, decreased memory and intellectual ability
*Diffuse Axonal Injury (DAI)*
- Widespread axonal damage after TBI
- Takes 12-24 hours or longer to develop
- decreased LOC, increased ICP, decortication or decerebration, and global cerebral
edema
- 90% of pts remain in persistant vegetative state
Focal Brain Injury - ANSWER: - Tissue damage is severe
- Surgical repair is impossible
*antibiotics (until meningitis ruled out*
unconsciousness,
*hemiplegia on the contralateral side*
*a dilated pupil on the ipsilateral side*
Contusions - ANSWER: - bruising of the brain tissue within a focal area
- usually associated with a closed head injury
- may continue to bleed and rebleed (blossom on CT scan)
