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: Antihypertensive medication lowers blood pressure, which reduces the risk of stroke caused by high blood pressure or hypertension.
Choice B: Anti-cholesterol medication lowers the level of cholesterol in the blood, which reduces the risk of stroke caused by atherosclerosis or plaque buildup in the arteries.
Choice C: Antiplatelet medication prevents blood clots from forming, which reduces the risk of stroke caused by ischemia or blockage of blood flow to the brain.
Choice D: All of the above medications are used to treat and prevent strokes, as they address different risk factors and causes of stroke.
Correct Answer is A
Explanation
Choice A: Maintenance of patent airway is correct because it is the most essential and urgent intervention on all head injury patients. A patent airway means that the airway is clear and open for breathing. A head injury can cause obstruction, swelling, bleeding, or paralysis of the airway, leading to hypoxia, brain damage, or death. The nurse should assess and secure the airway as the first step in the primary survey and provide oxygen, suction, or intubation as needed.
Choice B: Maintenance of skin integrity is incorrect because it is not the priority intervention on all head injury patients. Skin integrity means that the skin is intact and free of wounds, infections, or pressure injuries. A head injury can cause skin breakdown, especially in immobilized or unconscious patients. The nurse should prevent and treat skin problems as part of the secondary survey and provide wound care, hygiene, or pressure relief as needed.
Choice C: Prevention of sleep deprivation is incorrect because it is not the priority intervention on all head injury patients. Sleep deprivation means that the patient does not get enough quality or quantity of sleep. A head injury can cause sleep disturbances, such as insomnia, hypersomnia, or altered sleep-wake cycle. The nurse should promote sleep hygiene and rest as part of the ongoing care and provide a quiet, dark, and comfortable environment as needed.
Choice D: Fluid and electrolyte balance is incorrect because it is not the priority intervention on all head injury patients. Fluid and electrolyte balance means that the patient has adequate and stable levels of fluids and minerals in the body. A head injury can cause fluid and electrolyte imbalances, such as dehydration, overhydration, or hyponatremia. The nurse should monitor and regulate fluid and electrolyte status as part of the ongoing care and provide oral or intravenous fluids, medications, or dietary modifications as needed.
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