NCLEX RN Practice Question # 567
NCLEX Examination.
Practice Question # 567.
Nclex
HEAD INJURY
Description
- Head injury is the pathological result of any mechanical force to the skull, scalp, meninges, or brain.
- Open head injury occurs when there is a fracture of the skull or penetration of the skull by
- an object.
- Closed head injury is the result of blunt trauma (this is more serious than an open head injury because of the chance of increased ICP in a “closed” vault); this type of injury can also be caused by shaken baby syndrome.
Early signs
- Slight change in vital signs
- Slight change in level of consciousness
- Infant: Irritability, high-pitched cry, bulging fontanel, increased head circumference, dilated scalp veins, Macewen’s sign (cracked-pot sound on percussion of the head), setting sun sign (sclera visible above the iris)
- Child: Headache, nausea, vomiting, visual disturbances (diplopia), seizures
Late signs
- Decrease in level of consciousness
- Bradycardia
- Decreased motor and sensory responses
- Alteration in pupil size and reactivity
- Decorticate (flexion) posturing: Adduction of the arms at the shoulders; arms are flexed on the chest with the wrists flexed and the hands fisted, and the lower extremities are extended and adducted; seen with severe dysfunction of cerebral cortex.
- Decerebrate (extension) posturing: Rigid extension and pronation of the arms and the legs; sign of dysfunction at the level of the midbrain.
- Cheyne-Stokes respirations
- Coma