Meet the Patient: Jeff Dickson Traumatic Brain Injury
Jeff Dickson is a 17-year-old admitted to the Emergency Department via ambulance following a motor vehicle accident (MVA). He is accompanied by his parents and two of the three friends who were in the vehicle with him. Another friend, who was driving the vehicle, was transported to a different hospital by LifeCare Helicopter. A basilar skull fracture is a linear skull fracture that extends over the base of the frontal and temporal lobes. The nurse knows that this particular type of fracture can cause damage to the nerve pathways, cranial nerves, or vital centers. Jeff's vital signs and neurologic status will be monitored frequently.
1. Which assessment technique allows the nurse to assess for Battle's sign? A) Assess Jeff's pupillary response to light. B) Observe the area behind Jeff's ears. C) Observe the area around Jeff's eyes. D) Test Jeff's ability to follow directions. Other manifestations of a basilar skull fracture include tinnitus, facial paralysis, hearing difficulty, epistaxis, and CSF (cerebral spinal fluid) leakage from the nose or ears. The nurse is concerned about the rhinorrhea that Jeff is experiencing. 2. What methods can the nurse use to determine if the drainage is CSF? A) Measure the specific gravity of the drainage. B) Measure the spinal fluid pressure. C) Observe for a "halo" around a spot of drainage. D) Measure the quantity of the drainage. Nursing Plans and Interventions: The nurse applies a sterile nasal drip pad and initiates interventions to prevent increased intracranial pressure (ICP). 3. Which nursing intervention should be initiated to prevent increased ICP? A) Apply a hyperthermia blanket. B) Administer a prescribed stool softener as needed (PRN). C) Keep wrist restraints in place. D) Pack the nares with sterile gauze. Jeff requests "something for his headache."
4. Which medication is best for the nurse to administer to Jeff for his complaint of headache? A)...