Traumatic Brain Injury

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Sample questions from Traumatic Brain Injury

This material has 90 questions with answers and rationales. Here are the first 5.

1. 1.In the emergency department, a 22-year-old client with a TBI has a GCS of 7, a respiratory rate of 8/min, and SpO2 of 88% on room air. Which action should the nurse take first?

   • A.Insert an indwelling urinary catheter
   • B.Elevate the head of the bed to 30 degrees
   • C.Obtain a detailed history from the family
   • D.Prepare for airway support and assist ventilation

   Rationale: A GCS of 7 with hypoventilation and hypoxemia signals inability to protect the airway; airway support and ventilation take priority. A history and urinary catheter can wait until breathing is supported. Head elevation can help reduce intracranial pressure but does not correct the immediate airway threat.

2. 2.In the neuro intensive care unit, a 34-year-old client with a severe TBI has an ICP of 24 mm Hg, a MAP of 82 mm Hg, and a CPP of 58 mm Hg. Which actions should the nurse take? Select all that apply.

   • A.Place the client in Trendelenburg position
   • B.Elevate the head of the bed about 30 degrees and keep the head midline
   • C.Cluster all nursing care to minimize interruptions
   • D.Notify the provider about the elevated ICP and low CPP
   • E.Maintain prescribed sedation and analgesia

   Rationale: Head elevation with neutral alignment supports venous drainage, and prescribed sedation and analgesia reduce stimulation and metabolic demand. An ICP of 24 mm Hg and CPP of 58 mm Hg require prompt reporting and intervention. Clustering care can create prolonged stimulation, and Trendelenburg positioning can impede venous drainage and increase ICP.

3. 3.At change of shift in a trauma unit, a 41-year-old client with a TBI has a new unilateral dilated pupil and increasing drowsiness. Which action is the priority?

   • A.Document the findings and continue routine checks
   • B.Give the prescribed oral analgesic
   • C.Notify the rapid response team or provider immediately
   • D.Reassess the pupil in 1 hour

   Rationale: A new unilateral dilated pupil with declining alertness can indicate worsening intracranial pressure or herniation and requires immediate escalation. Waiting an hour risks irreversible injury. Oral medication and routine documentation do not address the acute neurologic change.

4. 4.In the neuro ICU, a 53-year-old client with a TBI has a serum sodium of 151 mEq/L, urine output of 450 mL/hr for 2 hours, and urine specific gravity of 1.002. Which complication should the nurse suspect?

   • A.Fluid overload from excess antidiuretic hormone
   • B.Diabetes insipidus
   • C.Syndrome of inappropriate antidiuretic hormone secretion
   • D.Acute kidney injury from oliguria

   Answer and rationale are in the full material.

5. 5.In a rehabilitation hospital, a 67-year-old client with a TBI has stable vital signs and needs assistance with a routine bath. Which task is appropriate to delegate to an experienced nursing assistant?

   • A.Assist with the bath and report any change in responsiveness
   • B.Evaluate the client's response to a new antiseizure medication
   • C.Teach the family how to prevent aspiration
   • D.Determine whether the client's confusion is worsening

   Answer and rationale are in the full material.