GCS
What is a normal GCS score
A. 10
B. 12
C. 13
D. 15
Correct Answer: D
Rationale:
Which statement best describes secondary brain injury?
A. Damage that occurs at the moment of impact
B. Injury caused by direct trauma only
C. Damage that occurs after the initial injury due to swelling and pressure
D. Injury caused only by skull fractures
Correct Answer: C
Rationale:
Which patient should the nurse see FIRST?
A. Patient with TBI complaining of mild headache
B. Patient with TBI resting comfortably
C. Patient with TBI who is newly confused
D. Patient with TBI asking for water
Correct Answer: C
Rationale:
Which action increases ICP?
A. Head midline
B. Elevating HOB
C. Neck flexion
D. Normothermia
Correct Answer: C
Rationale:
Which finding is most concerning in a TBI patient?
A. Mild headache
B. Slight fatigue
C. Unequal pupils
D. Drowsiness
Correct Answer: C
Rationale:
a GCS score of 7 indicates what priority?
A. Discharge planning
B. Intubation
C. Physical therapy
D. Nutrition
Correct Answer: B
Rationale:
Which processes are involved in secondary brain injury?
Select all that apply:
A. Inflammatory response
B. Cytokine release
C. Vasogenic edema
D. Immediate impact injury
E. Breakdown of the blood-brain barrier
Correct Answers: A, B, C, E
Rationale:
Which patients require IMMEDIATE intervention?
Select all that apply:
A. Patient with unequal pupils
B. Patient with mild dizziness
C. Patient with posturing
D. Patient with improving LOC
E. Patient with repeated vomiting
Correct Answers: A, C, E
Rationale:
Which factors increase ICP?
A. Coughing
B. Maintaining neutral head position
C. Elevated CO₂
D. Pain
E. Fever
Correct Answers: A, C, D, E
Rationale:
Which findings indicate worsening neurological status?
A. Posturing
B. Increased alertness
C. Decreased LOC
D. Seizures
E. Stable pupils
Correct Answers: A, C, D
Rationale:
Which findings indicate worsening neurologic status?
Select all that apply:
A. Decreased LOC
B. Unequal pupils
C. Confusion
D. Increased alertness
E. Posturing
Correct Answers: A, B, C, E
Rationale:
A patient initially appears stable after a head injury but deteriorates several hours later. What is the MOST likely explanation?
A. Primary injury progression
B. Secondary injury development
C. Resolution of swelling
D. Decreased ICP
Correct Answer: B
Rationale:
Which action should the nurse take FIRST for a patient with suspected increased ICP?
A. Assess airway
B. Perform full neuro exam
C. Administer pain medication
D. Elevate HOB
Correct Answer: A
Rationale:
Why does elevated CO2 increase ICP?
A. Causes vasoconstriction
B. Decreases blood flow
C. Causes vasodilation
D. Reduces brain volume
Correct Answer: C
Rationale:
Which symptom is most associated with subarachnoid hemorrhage?
A. Gradual confusion
B. Lucid interval
C. Sudden severe headache
D. Memory loss
Correct Answer: C
Rationale:
A patient only responds to painful stimuli and withdraws from it. What level of consciousness is this?
A. Alert
B. Obtunded
C. Stupor
D. Coma
Correct Answer: C
Rationale:
Which findings occur as a result of vasogenic edema?
Select all that apply:
A. Fluid leaking into extracellular space
B. Breakdown of blood-brain barrier
C. Increased intracranial pressure
D. Immediate trauma at impact site
E. Protein-rich fluid accumulation
Correct Answers: A, B, C, E
Rationale:
Which findings indicate the need for immediate provider notification?
A. Decreased LOC
B. Stable vital signs
C. Unequal pupils
D. Slight fatigue
E. Cushing’s triad
Correct Answers: A, C, E
Rationale:
Which interventions help PREVENT ICP elevation?
A. Limit stimulation
B. Encourage coughing
C. Maintain normothermia
D. Keep head midline
E. Allow frequent repositioning with neck flexion
Correct Answers: A, C, D
Rationale:
Which complications can occur with TBI?
A. Seizures
B. Increased ICP
C. Meningitis
D. Improved cognition
E. Brain herniation
Correct Answers: A, B, C, E
Rationale:
Which finding requires IMMEDIATE intervention?
A. Mild headache
B. Slight confusion
C. Unequal pupils
D. Fatigue
Correct Answer: C
Rationale:
Which sequence best explains the progression of secondary brain injury?
A. Trauma → decreased ICP → improved perfusion → recovery
B. Trauma → cytokine release → edema → increased ICP → decreased oxygen delivery
C. Trauma → vasoconstriction → decreased blood flow → decreased ICP
D. Trauma → immediate cell death → no further changes
Correct Answer: B
Rationale:
A nurse is caring for multiple patients with TBI. Which patient is PRIORITY?
A. Patient with GCS 15 and mild headache
B. Patient with GCS 13 and stable
C. Patient with GCS 9 who is becoming more lethargic
D. Patient with GCS 14 requesting pain medication
Rationale:
Which situation places a TBI patient at greatest risk for worsening ICP?
A. Calm, resting patient
B. Controlled ventilation
C. Elevated CO2 levels
D. Head elevated
Correct Answer: C
Rationale:
A patient develops posturing, unequal pupils, and decreasing LOC. What is the nurse’s priority interpretation?
A. Improvement
B. Mild concussion
C. Brain herniation risk
D. Stable condition
Correct Answer: C
Rationale: