Spinal cord/ head injury

A patient is admitted to the emergency department after a diving accident. The nurse notes the injury is at the C3 level. What is the priority nursing intervention?

A. Assess for bladder distention.

B. Prepare for immediate endotracheal intubation.

C. Apply a cervical collar.

D. Monitor for signs of neurogenic shock.

B. Prepare for immediate endotracheal intubation.

what reflects a sudden depression of reflex activity (areflexia) below the level of injury; muscles are flaccid and reflexes are absent

spinal shock

Injuries at C4 or above cause paralysis of the diaphragm, often requiring?

because acute respiratory failure is a leading cause of death.

ventilator support

what type of injuries result from initial trauma and are usually permanent

primary

what type of injuries may be seen for edema hemorrhage as a result from initial injury and are a major concern for critical care nurses

secondary

what is this?

an acute life-threatening emergency characterized by severe hypertension and exaggerated autonomic responses to harmless stimuli

autonomic dysreflexia

what causes decreases in blood pressure, heart rate (bradycardia), and cardiac output due to the loss of autonomic nervous system function.

neurogenic shock

A patient with a T4 SCI reports a "pounding" headache and is profusely sweating on their forehead. The nurse notes a BP of 190/110 mmHg. What is the first action the nurse should take?

A. Administer IV hydralazine as prescribed.

B. Check the patient for a distended bladder.

C. Place the patient in a sitting position.

D. Examine the rectum for a fecal mass.

C. Place the patient in a sitting position.

(Rationale: The patient is experiencing autonomic dysreflexia, an emergency situation. The first measure is to place the patient immediately in a sitting position to lower the blood pressure))

Which assessment finding would the nurse expect in a patient experiencing spinal shock shortly after an injury?

A. Hypertension and tachycardia.

B. Spasticity of the lower extremities.

C. Absence of reflexes below the level of injury.

D. Profuse sweating below the lesion.

C. Absence of reflexes below the level of injury.

A patient has an incomplete SCI classified as Anterior Cord Syndrome. Which sensation does the nurse expect the patient to retain?

A. Pain and temperature.

B. Motor function below the lesion.

C. Light touch, position, and vibration.

‘D. Movement of the upper extremities.

C. Light touch, position, and vibration.

(Rationale: In anterior cord syndrome, light touch, position, and vibration sensation remain intact, while pain, temperature, and motor function are lost below the level of the lesion))

A patient with a suspected SCI is being transported. Which principle of immobilization must the nurse ensure is followed?

A. The patient should be kept in a side-lying position to prevent aspiration.

B. The patient must be maintained in an extended position with no twisting.

C. The patient should be placed in a semi-Fowler’s position for breathing.

D. The head should be rotated every 2 hours to prevent pressure injuries.

B. The patient must be maintained in an extended position with no twisting.

A nurse is caring for a patient in neurogenic shock. Which clinical manifestation should the nurse anticipate?

A. Tachycardia and cool, clammy skin.

B. Bradycardia and hypotension.

C. Hyperthermia and rapid respirations.

D. Increased cardiac output and hypertension.

B. Bradycardia and hypotension.

Which of the following is the most common cause of autonomic dysreflexia?

A. Pressure injuries.

B. Fecal impaction.

C. Distended bladder.

D. Cold drafts.

C. Distended bladder.

A patient has a "Brown-Séquard" (Lateral Cord Syndrome) injury from a knife wound. What should the nurse expect to find on assessment?

A. Loss of motor function on the side opposite the injury.

B. Loss of pain and temperature on the same side as the injury.

C. Ipsilateral paralysis and contralateral loss of pain and temperature.

D. Total loss of sensation and motor function below the lesion.

C. Ipsilateral paralysis and contralateral loss of pain and temperature.

Lateral cord syndrome results in ____ and contralateral (opposite side) is

ipsilateral (same side) paralysis/loss of touch

loss of pain and temperature.

During the hyperacute phase of SCI, what is the target Mean Arterial Pressure (MAP)?

A. 60 mm Hg.

B. 75 mm Hg.

C. 85 mm Hg or higher.

D. 110 mm Hg or higher.

C. 85 mm Hg or higher.

(Rationale: Hypotension can further damage the spinal cord; therefore, the MAP should be maintained at 85 mm Hg or higher during the hyperacute phase))

A patient with SCI is at high risk for Venous Thromboembolism (VTE). Which nursing action is contraindicated?

A. Applying anti-embolism stockings.

B. Massaging the patient’s calves or thighs.

C. Administering low-molecular-weight heparin.

D. Measuring thigh and calf circumference daily.

B. Massaging the patient’s calves or thighs.

A nurse is teaching a patient with paraplegia about preventing pressure injuries. Which instruction is most important?

A. Shift weight in the wheelchair every 4 hours.

B. Use a mirror to inspect skin morning and night.

C. Apply thick powder inside the halo vest or braces.

D. Wash skin with harsh antibacterial soap daily.

B. Use a mirror to inspect skin morning and night.

A patient with a high cervical injury is undergoing "assisted coughing." How should the nurse perform this?

A. Have the patient use a spirometer every hour.

B. Apply pressure similar to abdominal thrusts to help clear secretions.

C. Perform vigorous chest percussion every 2 hours.

D. Suction the patient’s airway every 30 minutes regardless of breath sounds.

B. Apply pressure similar to abdominal thrusts to help clear secretions.

Which medication is commonly used to manage muscle spasticity in a patient with chronic SCI?

A. Hydralazine.

B. Baclofen.

C. Methylprednisolone.

D. Heparin.

B. Baclofen.

A patient in a halo vest complains that the frame is making a "startling noise" when objects touch it. What is the nurse’s best response?

A. "I will call the doctor to have the pins tightened immediately."

B. "That noise indicates the pins are likely infected."

C. "It is normal to be bothered by this initially, but you will adapt to it."

D. "We need to remove the vest and place you back in traction."

C. "It is normal to be bothered by this initially, but you will adapt to it."

A patient with SCI is experiencing "Poikilothermia." What does this mean for nursing care?

A. The patient will have a constant high fever.

B. The patient’s body temperature will depend on the surroundings.

C. The patient will sweat excessively below the level of injury.

D. The patient requires a cooling blanket at all times.

B. The patient’s body temperature will depend on the surroundings.

When performing a bowel program for a patient with a lesion above the sacral segments, which technique is used to stimulate defecation?

A. Administration of large-volume enemas daily.

B. Digital stimulation (anal massage).

C. Vigorous abdominal massage.

D. Application of cold packs to the abdomen.

B. Digital stimulation (anal massage).

What is the leading cause of death for persons with a spinal cord injury?

A. Myocardial infarction.

B. Autonomic dysreflexia.

C. Pneumonia, PE, and sepsis.

D. Hemorrhagic stroke.

C. Pneumonia, PE, and sepsis.

A nurse is caring for a patient with Central Cord Syndrome. Which assessment finding is characteristic of this syndrome?

A. Total loss of function in the lower extremities only.

B. Motor deficits greater in the upper extremities than the lower extremities.

C. Loss of vibration sense but intact pain sensation.

D. Ipsilateral loss of motor function and contralateral loss of sensation.

B. Motor deficits greater in the upper extremities than the lower extremities.

A patient with SCI is being started on a bladder program. What is the preferred method to prevent overdistention and infection?

A. Permanent indwelling Foley catheter.

B. Intermittent catheterization.

C. Encouraging the patient to "hold it" as long as possible.

D. Restricting fluids to less than 1 liter per day.

B. Intermittent catheterization.

(reduce the high risk of UTI associated with indwelling catheters.))

A patient with SCI is at risk for orthostatic hypotension. Which intervention should the nurse implement?

A. Change the patient’s position rapidly to build tolerance.

B. Apply an abdominal binder and anti-embolism stockings.

C. Keep the patient strictly supine for the first 4 months.

D. Discontinue all vasopressor medications.

B. Apply an abdominal binder and anti-embolism stockings.

A nurse is cleaning the pin sites of a patient in a halo brace. Which finding should be reported immediately?

A. Small amount of clear drainage.

B. Redness and loosening of a pin.

C. The patient reporting a mild headache.

D. Crusting around the pin site.

B. Redness and loosening of a pin.

Which spinal levels are most susceptible to injury due to high mobility?

A. C1–C2 and T5–T6.

B. C5–C7, T12, and L1.

C. T1–T4 and L5.

D. S1–S5 only.

B. C5–C7, T12, and L1.

A nurse is planning care for a patient with paraplegia. Which muscles are most important to strengthen for eventual crutch walking?

A. Hamstrings and quadriceps.

B. Triceps and latissimus dorsi.

C. Abdominals and calves.

D. Neck and jaw muscles.

B. Triceps and latissimus dorsi.

To prevent footdrop in a patient with SCI, the nurse should prioritize which action?

A. Keeping the patient’s legs in a flexed position.

B. Applying splints and removing them every 2 hours. C. Massaging the Achilles tendon vigorously.

D. Encouraging the patient to walk immediately after injury.

B. Applying splints and removing them every 2 hours.

what hematomas are common in older adults due to brain atrophy.

Symptoms may not appear for 3 weeks to months and often include ?

chronic subdural

fluctuating personality changes and headaches

A patient with an SCI is taking Sildenafil (Viagra). What is the primary purpose of this medication in this population?

A. To treat hypertension.

B. To manage neurogenic bladder.

C. To treat erectile dysfunction.

D. To prevent venous thromboembolism.

C. To treat erectile dysfunction.

A nurse observes a patient’s weights for skeletal traction hanging on the floor. What is the priority action?

A. Lift the weights and place them on the bed.

B. Adjust the weights so they are hanging freely (unencumbered).

C. Remove the weights until the doctor arrives.

D. Add more weight to ensure traction is maintained.

B. Adjust the weights so they are hanging freely (unencumbered).

A patient with SCI is receiving a high-protein diet. Why is this necessary?

A. To prevent the development of kidney stones.

B. To maintain the immune system and prevent muscle wasting.

C. To increase the risk of autonomic dysreflexia.

D. To prevent orthostatic hypotension.

B. To maintain the immune system and prevent muscle wasting.

What is "Heterotopic Ossification," a potential long-term complication of SCI?

A. Permanent loss of bone density.

B. Overgrowth of bone in the joints (e.g., hips, knees).

C. Spontaneous fractures of the spine.

D. Inflammation of the spinal cord.

B. Overgrowth of bone in the joints (e.g., hips, knees).

A nurse is caring for a patient with a T1 injury. Which respiratory function is likely to be impaired? A. Diaphragmatic breathing.

B. Use of intercostal muscles.

C. Only the ability to speak.

D. No respiratory impairment at this level.

use of intercostal muscles.

A patient with a halo vest needs their torso washed. How should the nurse proceed?

A. Remove the vest entirely for 30 minutes.

B. Open the vest at the sides and keep the liner dry.

C. Use a hose to spray water inside the vest.

D. Use a heavy amount of powder to prevent moisture.

B. Open the vest at the sides and keep the liner dry.

Which of the following is a symptom of a Pulmonary Embolism (PE) in an SCI patient?

A. Bradycardia and hypertension.

B. Pleuritic chest pain and shortness of breath.

C. Increased urine output.

D. Profuse sweating on the legs

B. Pleuritic chest pain and shortness of breath.

How often should passive range-of-motion (ROM) exercises be performed for an immobile SCI patient?

A. Once daily.

B. Every 12 hours.

C. At least four to five times daily.

D. Only when the patient requests them.

C. At least four to five times daily.

A nurse is palpating the lower abdomen of a patient with spinal shock. What is the nurse assessing for?

A. Ascites.

B. Urinary retention and bladder distention.

C. Aortic aneurysm.

D. Rebound tenderness from appendicitis.

B. Urinary retention and bladder distention.

A patient with SCI is prone to "Disuse Syndrome." Which intervention helps prevent this?

A. Maintaining strict bed rest for 6 months.

B. Range-of-motion exercises and frequent repositioning.

C. High-carbohydrate, low-protein diet.

D. Limiting all physical activity to save energy.

B. Range-of-motion exercises and frequent repositioning.

A patient with a sacral segment injury is starting a bowel program. Why is digital stimulation contraindicated for this patient?

A. The patient might experience a seizure.

B. The anus may be relaxed and lack tone in sacral injuries.

C. It will cause the patient to become hypertensive.

D. It is only contraindicated for cervical injuries.

B. The anus may be relaxed and lack tone in sacral injuries.

What is the most common type of SCI?

A. Complete paraplegia.

B. Incomplete tetraplegia.

C. Complete tetraplegia.

D. Incomplete paraplegia.

B. Incomplete tetraplegia.

A patient is being evaluated for a suspected ligamentous injury after a negative X-ray. Which diagnostic test is most likely to be ordered?

A. CT scan. B. MRI scan. C. Myelogram. D. Ultrasound

B. MRI scan

A patient with SCI is participating in sexual counseling. What should the nurse emphasize?

A. Sexual relationships are no longer possible.

B. Counseling should only involve the patient, not the partner.

C. Modifications and special techniques can allow for meaningful relationships.

D. Birth control is not necessary since SCI causes infertility.

C. Modifications and special techniques can allow for meaningful relationships.

A nurse is caring for a patient with a halo device. A pin becomes detached. What is the immediate priority?

A. Try to screw the pin back in.

B. Notify the doctor while another person stabilizes the head in a neutral position.

C. Remove the entire vest and frame.

D. Have the patient walk to the X-ray department.

B. Notify the doctor while another person stabilizes the head in a neutral position

A nurse is caring for a patient who just arrived at the Emergency Department (ED) after a motor vehicle accident. Which action is the absolute priority?

A. Assess the patient’s Glasgow Coma Scale (GCS) score.

B. Immobilize the cervical spine.

C. Inspect the scalp for lacerations.

D. Check for a "halo sign" on the bedsheets.

B. Immobilize the cervical spine.

what is often characterized by a brief loss of consciousness, followed by a lucid interval where the patient is awake, before rapid deterioration as ICP rises.

epidural hematoma

A patient with a severe TBI has a Cerebral Perfusion Pressure (CPP) of 58 mm Hg. How should the nurse interpret this finding?

A. This is a normal finding for a patient with a TBI.

B. The CPP is too high, risking cerebral hemorrhage.

C. The CPP is low; the goal for TBI patients is a minimum of 70 mm Hg.

D. The CPP is low; the goal for TBI patients is a minimum of 60 mm Hg

C. The CPP is low; the goal for TBI patients is a minimum of 70 mm Hg.

Which physiological process describes the Monro–Kellie hypothesis?

A. The brain cannot store oxygen or glucose, so blood flow must be constant.

B. As the brain swells, blood vessels are compressed, slowing blood flow.

C. The cranial vault is a closed system; if one component (brain, blood, CSF) increases, another must decrease.

D. Secondary injury occurs hours to days after the initial trauma.

C. The cranial vault is a closed system; if one component (brain, blood, CSF) increases, another must decrease.

(Rationale: The Monro–Kellie hypothesis states that because the skull is rigid, an increase in one of the three components must be compensated by a decrease in another, or ICP will rise.)

A nurse notes clear drainage from the nose of a patient with a frontal skull fracture. Which action is most appropriate?

A. Perform a glucose check on the drainage.

B. Use a gauze to check for the "halo sign."

C. Suction the nose to prevent aspiration.

D. Instruct the patient to blow their nose to clear the passage

A. Perform a glucose check on the drainage.

A patient is admitted with a "lucid interval" followed by rapid deterioration in consciousness. The nurse suspects which type of injury?

A. Subdural hematoma

B. Epidural hematoma

C. Concussion

D. Diffuse Axonal Injury (DAI)

B. Epidural hematoma

An older adult patient is brought to the clinic with "fluctuating" personality changes and a persistent headache that began three weeks after a minor fall. The nurse suspects:

A. Acute subdural hematoma

B. Chronic subdural hematoma

C. Epidural hematoma

D. Ischemic stroke

B. Chronic subdural hematoma

Which assessment finding is one of the three "cardinal signs" of brain death?

A. Decerebrate posturing

B. Fixed and dilated pupils

C. Absence of brain stem reflexes

D. Glasgow Coma Scale score of 3

C. Absence of brain stem reflexes

(Rationale: The three cardinal signs of brain death are coma, the absence of brain stem reflexes, and apnea))

A patient with a head injury has a GCS score of 7. The nurse should categorize this injury as:

A. Mild B. Moderate C. Severe D. Minimal

severe

A GCS score between __ and _ is generally accepted as indicating a severe head injury

3 and 8

Which of the following is a component of Cushing’s reflex (an ominous sign of increased ICP)?

A. Tachycardia

B. Decreasing systolic blood pressure

C. Narrowing pulse pressure

D. Widening pulse pressure

D. Widening pulse pressure

Signs of increasing ICP (Cushing’s reflex) include ___, ____ and _____

bradycardia, increasing systolic blood pressure, and widening pulse pressure.

A nurse is positioning a patient with increased ICP. Which position is most therapeutic?

A. Flat (supine) to maintain spinal alignment.

B. Head of bed (HOB) elevated 30 degrees with the neck in neutral alignment.

C. Trendelenburg to increase cerebral blood flow.

D. HOB elevated 90 degrees to maximize venous drainage

B. Head of bed (HOB) elevated 30 degrees with the neck in neutral alignment

Why is a rapid increase in body temperature (hyperthermia) considered "unfavorable" in a TBI patient?

A. It indicates the patient is developing a systemic infection.

B. It increases the metabolic demands of the brain and may indicate brain stem damage.

C. It causes the patient to shiver, which lowers ICP.

D. It indicates the patient is entering the rehabilitation phase

B. It increases the metabolic demands of the brain and may indicate brain stem damage.

(Rationale: Hyperthermia increases metabolic demands and is a poor prognostic sign that may indicate brain stem damage.))

A nurse is preparing to administer sedation to an agitated TBI patient. Why is Propofol often the "sedative of choice"?

A. It is the only sedative that does not cause respiratory depression.

B. It has a long half-life, providing consistent sedation for days.

C. It is short-acting and titratable, allowing for accurate periodic neurologic assessments.

D. It acts as an anticonvulsant to prevent late-onset seizures.

C. It is short-acting and titratable, allowing for accurate periodic neurologic assessments.

A patient has a suspected basilar skull fracture and requires nutritional support. Which route should the nurse anticipate for the feeding tube?

A. Nasogastric (NG) tube

B. Nasojejunal (NJ) tube

C. Oral feeding tube

D. Percutaneous endoscopic gastrostomy (PEG) tube

C. Oral feeding tube

(Rationale: If there is a suspicion of a skull base/basilar fracture, an oral tube should be used instead of a nasal tube to avoid potential entry into the cranial cavity))

A patient with a TBI is at risk for secondary brain injury. Which of the following is a primary cause of secondary injury?

A. The initial impact of the head against a windshield. B. A skull fracture sustained during a fall.

C. Hypotension and hypoxia following the accident.

D. A bullet wound through the parietal lobe.

C. Hypotension and hypoxia following the accident.

what type of injury results from inadequate delivery of oxygen and glucose to cells in the hours and days following the initial trauma.

Common causes include hypotension, hypoxia, and cerebral edema

secondary

Which statement regarding seizure prophylaxis in TBI patients is correct based on research evidence?

A. Anticonvulsants should be given for life after any head injury.

B. Anticonvulsants are effective in preventing "early" seizures (within 7 days) but not "late" seizures.

C. Seizures do not affect ICP, so prophylaxis is optional.

D. Only benzodiazepines should be used for seizure prevention.

B. Anticonvulsants are effective in preventing "early" seizures (within 7 days) but not "late" seizures.

A nurse assesses a patient’s motor response by pinching the pectoralis major muscle. This is done because:

A. Peripheral stimulation (like a nail bed pressure) can cause a reflex movement rather than a voluntary response.

B. Central stimulation is less painful for the patient.

C. It is the only way to test for decorticate posturing.

D. The pectoralis muscle is the most sensitive to light touch.

A. Peripheral stimulation (like a nail bed pressure) can cause a reflex movement rather than a voluntary response.

(Rationale: Applying a central stimulus (like pinching the pectoralis) is preferred because peripheral stimulation may result in a reflex movement, providing inaccurate data regarding voluntary motor response.))

A patient with a head injury develops "Battle sign." What does this indicate?

A. A fracture of the frontal bone.

B. A fracture of the base of the skull (basal skull fracture).

C. A subdural hematoma.

D. An epidural hematoma.

B. A fracture of the base of the skull (basal skull fracture).

what is ecchymosis (bruising) seen over the mastoid, which indicates a fracture of the base of the skull.

Battle sign

A patient is being monitored for increased ICP. Which of the following should the nurse avoid?

A. Administering stool softeners.

B. Suctioning the patient only when necessary.

C. Encouraging the patient to perform the Valsalva maneuver to move up in bed.

D. Maintaining a quiet, low-stimulus environment.

C. Encouraging the patient to perform the Valsalva maneuver to move up in bed.

(Rationale: The Valsalva maneuver (straining) increases intracranial pressure and should be avoided in patients with head injuries.)

what is titratable and has a short half-life, making it the preferred sedative for maintaining the ability to perform neurologic checks

propofol

A patient with a concussion is being discharged from the ED. Which symptom should the nurse instruct the family to report immediately?

A. A mild headache that responds to acetaminophen. B. Feeling tired and wanting to nap.

C. One-time vomiting shortly after getting home.

D. Slurred speech or weakness in the arms/legs.

D. Slurred speech or weakness in the arms/legs.

When assessing pupils, the nurse notes that both are fixed and dilated. This finding typically indicates:

A. The patient is emerging from a coma.

B. Acute injury and intrinsic damage to the upper brain stem.

C. A small, compensated subdural hematoma.

D. The effect of benzodiazepine administration.

B. Acute injury and intrinsic damage to the upper brain stem.

A nurse is caring for a patient with Diffuse Axonal Injury (DAI). What is a hallmark clinical characteristic of this condition?

A. A brief loss of consciousness followed by a "lucid interval."

B. Widespread shearing and rotational forces causing immediate coma and no lucid interval.

C. Bleeding specifically limited to the temporal lobe. ‘

D. A simple linear break in the continuity of the skull bone.

B. Widespread shearing and rotational forces causing immediate coma and no lucid interval.

Which electrolyte imbalance is common after a head injury and can cause increasing lethargy and seizures?

A. Hyperkalemia

B. Hypocalcemia

C. Hyponatremia

D. Hypophosphatemia

C. Hyponatremia

(Rationale: Hyponatremia is common after head injury due to shifts in fluid and electrolytes or conditions like SIADH))

A patient’s family asks why the nurse is checking the bedsheets for a "halo sign." The nurse explains it is used to:

A. Detect the presence of infection in a scalp wound.

B. Identify if bloody drainage contains cerebrospinal fluid (CSF).

C. Determine if the patient has a concussion.

D. Assess the depth of a scalp laceration

B. Identify if bloody drainage contains cerebrospinal fluid (CSF).

(Rationale: To check for the halo sign, the nurse dabs bloody drainage with gauze; if a ring of fluid forms around the blood stain, it indicates the presence of CSF.)

A patient with a temporal lobe contusion is at high risk for which complication?

A. Basilar skull fracture

B. Herniation syndromes

C. Chronic Traumatic Encephalopathy (CTE)

D. Scalp avulsion

B. Herniation syndromes

Temporal lobe contusions are associated with significant edema and hemorrhage that peak at ____?hours, potentially causing increased ICP and herniation syndromes.

18-36

A nurse is using a cooling device to treat a fever in a TBI patient. The nurse must be careful to avoid inducing:

A. Hypotension

B. Shivering

C. Hypertension

D. Diuresis

B. Shivering

Which score is the lowest possible on the Glasgow Coma Scale (GCS)?

A. 0 B. 1 C. 3 D. 5

C. 3

A patient with a severe head injury is a potential organ donor. Who is responsible for confirming brain death using signs like apnea and absence of reflexes?

A. The nurse manager

B. The organ procurement team

C. The clinical examiner (physician)

D. The patient's next of kin

C. The clinical examiner (physician)

Chronic Traumatic Encephalopathy (CTE) is most commonly associated with:
A. A single severe epidural hematoma.

B. Repeated concussive incidents in contact sports.

C. A one-time basilar skull fracture.

D. Congenital brain atrophy.

B. Repeated concussive incidents in contact sports.

A nurse is caring for a patient with an intracerebral hemorrhage. Which condition is a common non-traumatic cause of this type of bleeding?

A. Hypotension

B. Systemic hypertension

C. Iron-deficiency anemia

D. Hypoglycemia

B. Systemic hypertension

Which nursing intervention helps reduce agitation without affecting the accuracy of neurologic assessments?

A. Applying physical restraints.

B. Administering long-acting benzodiazepines.

C. Using Propofol for sedation.

D. Keeping the room lights as bright as possible.

C. Using Propofol for sedation.

A patient’s family states, "He’s just not the same person anymore" after a TBI. The nurse understands this is likely due to:

A. A lack of motivation in the patient.

B. Personality changes that occur in many patients comatose for more than 6 hours.

C. The patient's refusal to participate in physical therapy.

D. A temporary side effect of pain medication.

B. Personality changes that occur in many patients comatose for more than 6 hours.

What is the goal blood glucose range for a patient with a TBI to prevent complications?

A. 60–100 mg/dL

B. 80–160 mg/dL

C. 140–200 mg/dL

D. Any level below 250 mg/dL

B. 80–160 mg/dL

A nurse is managing a patient with a scalp laceration. Why is the area irrigated before suturing?

A. To stop the profuse bleeding from the scalp.

B. To reduce the risk of intracranial infection from organisms.

C. To numb the area before the procedure.

D. To check for the presence of CSF.

B. To reduce the risk of intracranial infection from organisms.

In a patient with a head injury, "restlessness" can be a sign of many things. Which of the following is the most life-threatening cause of restlessness?

A. A full bladder

B. Pain

C. Hypoxia

D. Discomfort from an IV line

C. Hypoxia

A patient is being evaluated for a "depressed skull fracture." What is the typical treatment for this?

A. Immediate discharge with home observation.

B. Surgery to elevate the skull and debride the area within 24 hours.

C. Application of a tight pressure dressing.

D. No treatment is needed as the bone will pop back out.

B. Surgery to elevate the skull and debride the area within 24 hours.

The nurse knows that the GCS is considered the "most sensitive indicator" for which of the following?

A. A lapse in neurologic functioning and acute changes in ICP.

B. The patient's ability to return to work.

C. The presence of a basilar skull fracture.

D. The need for a blood transfusion.

A. A lapse in neurologic functioning and acute changes in ICP.

How long can improvement in status continue for a patient following a TBI?

A. 6 months

B. 1 year

C. 3 or more years

D. Only until the patient is discharged from the hospital

C. 3 or more years

A patient has a TBI and a suspected CSF leak from the ear (otorrhea). Which sign should the nurse look for over the mastoid?

A. Raccoon eyes

B. Battle sign

C. Halo sign

D. Cushing’s sign

battle sign

A patient with a TBI is considered "catabolic." This means the nurse should prioritize:

A. Restricting all calories to prevent weight gain.

B. Early initiation of nutritional therapy (enteral or parenteral).

C. Delaying feeding until the patient is fully awake.

D. Only providing clear liquids for the first week

B. Early initiation of nutritional therapy (enteral or parenteral).

A nurse is assessing for lower extremity motor strength in a conscious TBI patient. The correct method is to:

A. Pinch the patient's toes and watch for a reflex.

B. Ask the patient to push their feet down against the nurse's hands.

C. Perform a GCS assessment on the eyes only.

D. Raise the bed and see if the patient's legs fall.

B. Ask the patient to push their feet down against the nurse's hands.

(Rationale: Motor strength in the lower extremities is assessed by asking the patient to push down against the examiner’s hands)

Which classification describes a TBI where an object penetrates the skull and enters the brain?

A. Closed (blunt) TBI

B. Open (penetrating) TBI

C. Diffuse axonal injury

D. Cerebral contusion

B. Open (penetrating) TBI

A nurse is caring for a patient who just had a craniotomy for a subdural hematoma. What is a key post-operative priority?

A. Keeping the patient in a prone position.

B. Monitoring for a reaccumulation of blood via a surgical drain.

C. Encouraging vigorous coughing and deep breathing.

D. Rapidly decreasing the IV fluid rate to 25 mL/hr

B. Monitoring for a reaccumulation of blood via a surgical drain.

A nurse is educating a family about "cognitive sequelae" after a TBI. Which of the following should be included as a common symptom?

A. Improved ability to multitask.

B. Increased patience and empathy.

C. Impulsivity and distractibility.

D. Faster reading and writing speeds.

C. Impulsivity and distractibility.

A patient is recovering from a stab wound to the right

kidney. He is awake, alert and hemodynamically

stable. The trauma nurse is unconcerned to note

which assessment finding?

A. RLQ rebound tenderness on palpation

B. Ecchymosis along the right flank

C. Left shoulder pain unassociated with arm

movement

D. Muffled heart sounds and distended neck veins

B. Ecchymosis along the right flank

A 20-year–old patient, who suffered multiple

traumatic injuries from an MVC, is awaiting transfer

to the medical-surgical unit. Which finding, by the

ICU nurse, would halt the transfer?

A. The chest tube is still in place.

B. Glasgow coma scale of 14.

C. Post extubation PaCO2 is 55 mm Hg.

D. Enteral feedings are at 50% of goal.

C. Post extubation PaCO2 is 55 mm Hg.

(Prior to leaving the ICU, the patient should be hemodynamically stable with the ability to maintain oxygenation and clear their airway. The PaCO2 is elevated (the patient is 20 years old!) suggesting the inability to adequately ventilate. This patient may be in respiratory jeopardy and do poorly in a less monitored and more independent hospital environment. Answers A, B and D should not halt a transfer to the medical-surgical unit.))