NCLEX RN Practice Question # 567

NCLEX Examination.

Practice Question # 567.






  • 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.

Sign of Head Injury

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

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