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 Question 11 The admission orders for a patient with traumatic brain injury say to keep the patient’s head elevated with neutral body positioning. Which patient positioning would the nurse consider as meeting this requirement? 1. The patient’s head is supported on two pillows. 2. The head of the patient’s bed is elevated to 20 degrees. 3. The patient’s hips are flexed at less than 90 degrees. 4. The neck is in the patient’s position of comfort, which is rotated to the left. 5. The patient is facing forward. Question 12 A patient being treated for a traumatic brain injury is febrile with a temperature of 100°F. What is the priority nursing intervention? 1. Culture the patient’s urine. 2. Contact the primary health care provider. 3. Administer the prn antipyretic. 4. Have the patient cough and deep breath more frequently. Question 13 The patient with traumatic brain injury has been intubated and placed on mechanical ventilation. Which nursing interventions would help optimize oxygenation? 1. Preoxygenate the patient prior to suctioning. 2. Use very low vacuum pressure when suctioning the patient. 3. Limit suction passes to 10 seconds or less. 4. Suction when PaCO2 levels rise above 40 mm Hg. 5. Suction the patient before and after scheduled turns. Question 14 A patient being treated for a traumatic brain injury is demonstrating signs of contractures as a complication associated with immobility. Which nursing intervention is indicated? 1. Maintain neutral body position. 2. Turn and reposition every 4 hours. 3. Apply antiembolism stockings. 4. Ensure oxygen saturation level of 92%. Question 15 A patient with a traumatic brain injury is being treated for diabetes insipidus. Which finding would the nurse evaluate as indicating treatment is effective? 1. Potassium level has decreased. 2. Blood pressure has decreased. 3. Serum sodium level is increased. 4. Urine output has decreased. Question 16 A patient is admitted to the emergency department after sustaining injury in a fall. Which assessment findings would the nurse immediately communicate to the emergency department physician? 1. The patient is taking a sulfa drug for urinary tract infection. 2. The patient has a bluish discoloration behind his ear. 3. The patient’s nose is running. 4. The patient’s smile is crooked. 5. The patient’s tongue is lacerated. Question 17 A patient diagnosed with a traumatic brain injury is demonstrating signs of cerebral salt wasting. Which interventions would the nurse include in this patient’s plan of care? 1. Restrict fluids. 2. Restrict sodium. 3. Monitor intravenous normal saline administration. 4. Provide potassium chloride intravenous replacements. Question 18 A patient has been diagnosed with a benign brain tumor with resultant increase in intracranial pressure. The patient is confused and occasionally combative. His wife expresses concern about how to tell their two young sons. Which nursing diagnosis will guide initial selection of nursing interventions? 1. Ineffective Breathing Pattern 2. Decreased Intracranial Adaptive Capacity 3. Impaired Physical Mobility 4. Risk for Aspiration Question 19 A patient is brought to the hospital after being found in the floor at the bottom of a flight of stairs. The patient has an obvious depressed skull fracture and is bleeding from her right ear. Initially, the nurse assesses the patency of the patient’s airway, her breathing, and the rate and rhythm of her pulse. What assessments and questions will be part of the nurse’s secondary survey? 1. “How did the injury occur?” 2. “What care was provided at the site of the injury?” 3. “Has anything like this ever happened before?” 4. Blood pressure measurement will occur. 5. A general systems assessment will occur. Question 20 A patient being treated for a traumatic brain injury for 3 days begins to seize. Which intervention is the nurse’s priority? 1. Administer fosphenytoin (Cerebyx) 4 mg per kg of patient body weight. 2. Keep the patient safe and maintain the airway. 3. Lower the head of the bed. 4. Initiate a recording of the patient’s cardiac rhythm.