Author Question: An adolescent boy is brought to the emergency department after a motorcycle accident. His ... (Read 105 times)

kfurse · **on:** Jun 28, 2018

An adolescent boy is brought to the emergency department after a motorcycle accident. His respirations are deep, periodic, and gasping. There are extreme fluctuations in blood pressure. Pupils are dilated and fixed.

What type of head injury should the nurse suspect?
a. Brainstem c. Subdural hemorrhage
b. Skull fracture d. Epidural hemorrhage

Question 2

The nurse is assessing a child who was just admitted to the hospital for observation after a head injury. The most essential part of the nursing assessment to detect early signs of a worsening condition is:

a. Posturing. c. Focal neurologic signs.
b. Vital signs. d. Level of consciousness.

jaykayy05 · **Reply #1 on:** Jun 28, 2018

Answer to Question 1

ANS: A
Signs of brainstem injury include deep, rapid, periodic or intermittent, and gasping respirations. Wide fluctuations or noticeable slowing of the pulse, widening pulse pressure, or extreme fluctuations in blood pressure are consistent with a brainstem injury. Skull fracture and subdural and epidural hemorrhages are not consistent with these signs.

Answer to Question 2

ANS: D
The most important nursing observation is assessment of the child's level of consciousness. Alterations in consciousness appear earlier in the progression of head injury than do alterations of vital signs or focal neurologic signs. Neurologic posturing indicates neurologic damage. Vital signs and focal neurologic signs are later signs of progression when compared with level-of-consciousness changes.