Hematomas
A pt presents after head trauma with a brief loss of consciousness followed by a period of normal alertness. thirty minutes later, the patient becomes difficult to arouse and begins vomiting. what is the most likely diagnosis?
A. Subdural hematoma
B. Epidural hematoma
C. Intracerebral hemorrhage
D. Concussion
Correct Answer: B
Rationale:
Bruising behind the ear is noted in a patient after a head trauma. what condition should the nurse suspect?
A. Concussion
B. Epidural hematoma
C. Basilar skull fracture
D. Intracerebral hemorrhage
Correct Answer: C
Rationale:
Which is the EARLIEST sign of increased intracranial pressure?
A. Bradycardia
B. Decreased level of consciousness
C. Posturing
D. Seizures
Correct Answer: B
Rationale:
A patient is struck in the forehead with a baseball and sustains injury directly beneath the site of impact. What type of injury is this?
A. Coup
B. Contrecoup
C. Diffuse axonal injury
D. Contusion
Correct Answer: A
Rationale:
What is the FIRST priority in a patient with a traumatic brain injury?
A. Pain control
B. Airway management
C. Neurologic assessment
D. Positioning
Correct Answer: B
Rationale:
what findings are expected with a patient who is experiencing a chronic subdural hematoma?
Select all that apply:
A. Gradual confusion
B. Rapid coma
C. History of fall weeks ago
D. Personality changes
E. Sudden severe headache
Correct Answers: A, C, D
Rationale:
which findings are consistent with a basilar skull fracture?
Select all that apply:
A. Raccoon eyes
B. Halo sign
C. Battle’s sign
D. Sudden severe headache
E. Clear drainage from nose
Correct Answers: A, B, C, E
Rationale:
Which findings indicate increased ICP?
Select all that apply:
A. Headache
B. Vomiting
C. Confusion
D. Improved alertness
E. Pupillary changes
Correct Answers: A, B, C, E
Rationale:
A patient is hit in the front of the head, and imaging shows injury to the back of the brain. What type of injury is this?
A. Coup
B. Diffuse axonal injury
C. Contrecoup
D. Hematoma
Correct Answer: C
Rationale:
Which interventions help reduce ICP?
Select all that apply:
A. Elevate head of bed
B. Keep head midline
C. Flex the neck
D. Maintain normothermia
E. Monitor CO2 levels
Correct Answers: A, B, D, E
Rationale:
A pt has bleeding between the dura and arachnoid due to tearing of the bridging veins. which condition would you expect as the nurse?
A. Epidural hematoma
B. Subarachnoid hemorrhage
C. Subdural hematoma
D. Intracerebral hemorrhage
Correct Answer: C
Rationale:
A patient has clear drainage from the nose after a fall. What is the nurse’s PRIORITY action?
A. Insert nasal packing
B. Test drainage for CSF
C. Suction the airway
D. Place the patient flat
Correct Answer: B
Rationale:
A patient has bradycardia, widened pulse pressure, and irregular respirations. What does this indicate?
A. Normal variation
B. Early concussion
C. Cushing’s triad
D. Seizure onset
Correct Answer: C
Rationale:
Which findings are consistent with a concussion?
Select all that apply:
A. Confusion
B. Memory loss
C. Always involves loss of consciousness
D. Headache
E. Normal CT scan
Correct Answers: A, B, D, E
Rationale:
Why is monitoring CO2 levels important in a TBI patient?
A. CO2 decreases ICP
B. CO2 has no effect on brain pressure
C. Increased CO2 causes vasodilation and increases ICP
D. CO2 causes vasoconstriction and decreases ICP
Correct Answer: C
Rationale:
which patients are at the highest risk for a chronic subdural hematoma?
Select all that apply:
A. 85-year-old with history of falls
B. Patient on anticoagulants
C. Young athlete with concussion
D. Patient with brain atrophy
E. Patient with arterial bleed
Correct Answers: A, B, D
Rationale:
Which nursing interventions are appropriate for a suspected CSF leak?
Select all that apply:
A. Notify provider immediately
B. Insert cotton into ear
C. Test drainage for CSF
D. Monitor for infection
E. Encourage blowing nose
Correct Answers: A, C, D
Rationale:
Which interventions help LOWER ICP?
Select all that apply:
A. Elevate HOB
B. Keep head midline
C. Flex the neck
D. Maintain normothermia
E. Monitor CO2
Correct Answers: A, B, D, E
Rationale:
A patient involved in a high-speed MVC arrives unresponsive with no large localized bleed on CT. The patient demonstrates posturing and elevated ICP.
What is the most likely diagnosis?
A. Subdural hematoma
B. Concussion
C. Epidural hematoma
D. Diffuse axonal injury
Correct Answer: D
Rationale:
Which actions are appropriate for a patient with a suspected CSF leak?
Select all that apply:
A. Test drainage for CSF
B. Insert nasal packing
C. Notify provider
D. Monitor for infection
E. Encourage coughing
Correct Answers: A, C, D
Rationale:
A patient presents after trauma with a steady decline in LOC, headache, and vomiting. There is no lucid interval. CT shows a crescent-shaped bleed.
Which condition is MOST consistent?
A. Epidural hematoma
B. Subarachnoid hemorrhage
C. Subdural hematoma
D. Intracerebral hemorrhage
Correct Answer: C
Rationale:
A patient with a basilar skull fracture is most at risk for which complication?
A. Hypovolemia
B. Stroke
C. Pneumonia
D. Meningitis
Correct Answer: D
Rationale:
Why is increased CO2 dangerous in a TBI patient?
A. Causes vasoconstriction
B. Decreases cerebral blood flow
C. Causes vasodilation and increases ICP
D. Has no effect on ICP
Correct Answer: C
Rationale:
Which findings are associated with diffuse axonal injury (DAI)?
Select all that apply:
A. Decreased level of consciousness
B. Lucid interval
C. Posturing
D. Increased intracranial pressure
E. Widespread brain damage
Correct Answers: A, C, D, E
Rationale:
A patient with TBI becomes increasingly restless and difficult to arouse. What is the nurse’s PRIORITY action?
A. Administer pain medication
B. Reposition the patient
C. Notify the provider
D. Continue monitoring
Correct Answer: C
Rationale: