Page 2016 - Saunders Comprehensive Review For NCLEX-RN

3. Changes in personality or behavior, cranial nerve
deficits, and any other residual deficits depend on the
area of the brain damage and the extent of the
damage.
B. Types of head injuries (Box 58-9)
1. Open
a. Scalp lacerations
b. Fractures in the skull
c. Interruption of the dura mater
2. Closed
a. Concussions
b. Contusions
c. Fractures
C. Hematoma
1. Description: A collection of blood in the tissues that
can occur as a result of a subarachnoid hemorrhage or
an intracerebral hemorrhage.

2. Assessment

a. Assessment findings depend on the
injury.
b. Clinical manifestations usually result
from increased ICP.
c. Changing neurological signs in the
client
d. Changes in level of consciousness
e. Airway and breathing pattern changes
f. Vital signs change, reflecting increased
ICP.
g. Headache, nausea, and vomiting
h. Visual disturbances, pupillary changes,
and papilledema
i. Nuchal rigidity (not tested until spinal
cord injury is ruled out)
j. CSF drainage from the ears or nose
k. Weakness and paralysis
l. Posturing
m. Decreased sensation or absence of
feeling
n. Reflex activity changes
o. Seizure activity

CSF can be distinguished from other fluids

by the presence of concentric rings (bloody fluid
surrounded by yellowish stain; halo sign) when the
fluid is placed on a white sterile background, such
as a gauze pad. CSF also tests positive for glucose

2016