Which of the following describes an open traumatic brain injury?
Object penetrates the brain or trauma is so severe that the scalp and skull are opened
Stress
Acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue
All of the above
The Correct Answer is A
Choice A: Object penetrates the brain or trauma is so severe that the scalp and skull are opened is correct because it is the definition of an open traumatic brain injury. An open traumatic brain injury occurs when a foreign object such as a bullet, knife, or bone fragment enters the brain or when a blunt force trauma such as a fall, collision, or assault causes a fracture or laceration of the skull. This can damage the brain tissue, blood vessels, and nerves and cause bleeding, swelling, or infection.
Choice B: Stress is incorrect because it is not a type of traumatic brain injury. Stress is a psychological or emotional response to a challenging or threatening situation. It can affect the brain function and health, but it does not cause physical damage to the brain tissue.
Choice C: Acceleration/deceleration injury occurs when the head accelerates and then rapidly decelerates, damaging brain tissue is incorrect because it is not an open traumatic brain injury. It is a type of closed traumatic brain injury, which occurs when the head moves violently without breaking the skull. This can cause the brain to hit against the inner wall of the skull or twist within the skull, resulting in bruising, tearing, or shearing of the brain tissue.
Choice D: All of the above are incorrect because only choice a) describes an open traumatic brain injury. Choices b) and c) are not related to an open traumatic brain injury and do not match its characteristics. The nurse should know the different types and causes of traumatic brain injury and their implications for assessment and care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A: Return to hospital immediately if patient is having severe headache or vomiting is correct because it can indicate increased intracranial pressure, bleeding, swelling, or infection in the brain. These are serious complications that can cause permanent damage or death. The patient and family should seek medical atention as soon as possible and not wait for other symptoms to appear.
Choice B: Return to hospital immediately for changes in level of consciousness is correct because it can also indicate worsening brain injury or complications from a head injury. Changes in level of consciousness can include confusion, drowsiness, agitation, or loss of awareness. The patient and family should monitor the patient's mental status and alertness and report any changes to the doctor.
Choice C: Call ambulance if unable to arouse patient is correct because it can mean that the patient has lost consciousness or is in a coma. This is a medical emergency that requires immediate intervention and resuscitation. The patient and family should not atempt to move or transport the patient by themselves but call for professional help.
Choice D: All of the above are correct because they are important instructions for the patient and family to follow when discharging patient home following a head injury. They can help prevent further harm or complications and ensure prompt treatment and recovery. The nurse should educate the patient and family about these instructions and provide them with writen information and contact numbers.
Correct Answer is C
Explanation
Choice A: Headache is not a late sign of intracranial pressure, but rather an early sign of increased pressure or irritation of the meninges.
Choice B: Confusion is not a late sign of intracranial pressure, but rather an early sign of impaired cognition or orientation.
Choice C: Stupor to coma is a late sign of intracranial pressure, as it indicates a severe deterioration of consciousness or brain function.
Choice D: Weakness is not a late sign of intracranial pressure, but rather a sign of focal neurological deficit or hemiparesis.
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