Please provide complete, thorough, and detailed answers to all questions in the case study. Multiple-choice answers should include the correct choice and rationale for that choice and/or rationale why other choices are incorrect.

Please see attached file.

Case Study
Acute Head Injury

Difficulty: Advanced

Setting: Hospital

Index Words: head injury, trauma, crisis management, neurologic assessment

Giddens Concepts: Clinical Judgment, Culture, Intracranial Regulation

HESI Concepts: Assessment, Clinical Decision Making, Culture, Intracranial Regulation, Nursing Interventions

J.R. is a 28-year-old man who was doing home repairs. He fell from the top of a 6-foot stepladder, striking his head on a large rock. He experienced a momentary loss of consciousness. By the time his neighbor got to him, he was conscious but bleeding profusely from a laceration over the right temporal area. the neighbor drove him to the emergency department of your hospital. As the nurse, you immediately apply a cervical collar, lay him on a stretcher, and take J.R. to a treatment room.


1. What steps will you take to assess J.R.?

2. List at least five components of a neurologic examination.

3. What types of injuries may J.R. have sustained?

4. What complication common to each of these diagnoses concerns you most?

5. Identify at least six findings that would indicate this complication is occurring.

Part 1 Medical-Surgical caSeS


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6. What is the most sensitive indicator of neurologic change?

Case Study Progress

You complete your neurologic examination and find the following: Glasgow Coma Scale (GCS) score of 15; pupils equal, round, reactive to light; and full sensation intact. J.R. complains of a headache and is somewhat drowsy. His vital signs (VS) are 120/72, 114, 30, 98.7 ° F (37.1 ° C) and SpO2 94%. As the radiology technician performs a portable cross-table lateral cervical spine x-ray examination, J.R. begins to speak incoherently and appears to drift off to sleep.

7. What are the next actions you will take?

Case Study Progress

While waiting for the physician to arrive, you find that J.R. has become unresponsive to verbal stimuli. the right pupil is larger than the left and does not respond to light. J.R. responds to painful stimuli in the manner shown in the illustration.

8. What is this response cal