Traumatic and Acquired Brain Injuries Flashcards
A patient with a traumatic brain injury has an ICP of 22 mmHg. Which of the following interventions should the nurse implement first?
A) Lower the head of the bed to 10 degrees
B) Encourage the patient to cough and deep breathe
C) Elevate the head of the bed to 30 degrees
D) Administer 500 mL of normal saline rapidly
Correct Answer: C) Elevate the head of the bed to 30 degrees
Rationale: Elevating the head of the bed to 30 degrees promotes venous drainage from the brain, helping to lower intracranial pressure (ICP).
Lowering the head of the bed(A) can increase ICP.
Encouraging coughing and deep breathing (B) increases intrathoracic pressure, which can raise ICP.
Rapid fluid administration (D) can contribute to increased cerebral edema and further elevate ICP.
A patient with suspected increased intracranial pressure (IICP) presents with bradycardia, irregular respirations, and widening pulse pressure. The nurse recognizes this as:
A) Cushing’s triad
B) Battle sign
C) Decerebrate posturing
D) Glasgow Coma Scale deterioration
Correct Answer: A) Cushing’s triad
Rationale: Cushing’s triad is a late sign of increased ICP and includes hypertension with a widening pulse pressure, bradycardia, and irregular respirations. Battle sign (B) refers to bruising behind the ear, indicative of a basilar skull fracture. Decerebrate posturing (C) is a sign of severe brain injury but is not specific to IICP. A deteriorating Glasgow Coma Scale (D) is concerning but does not specifically describe Cushing’s triad.
The nurse is caring for a patient with a head injury who is at risk for increased intracranial pressure. Which of the following actions should the nurse avoid?
A) Keeping the head midline and elevated at 30 degrees
B) Administering stool softeners to prevent straining
C) Suctioning the airway frequently and aggressively
D) Maintaining a quiet, low-stimulation environment
Correct Answer: C) Suctioning the airway frequently and aggressively
Rationale: Frequent or aggressive suctioning increases intrathoracic pressure and can raise ICP. The correct interventions include keeping the head midline and elevated at 30 degrees (A) to facilitate venous drainage, using stool softeners (B) to prevent straining, and maintaining a quiet environment (D) to reduce stimulation and prevent spikes in ICP.
A nurse is assessing a patient with increased intracranial pressure (IICP). Which early sign would alert the nurse to worsening IICP?
A) Bradycardia
B) Vomiting without nausea
C) Change in level of consciousness
D) Fixed, dilated pupils
Correct Answer: C) Change in level of consciousness
Rationale: The earliest and most sensitive indicator of IICP is a change in the level of consciousness. Bradycardia (A) and fixed, dilated pupils (D) are late signs. Vomiting without nausea (B) can be a sign but is not the earliest indicator.
A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 6. What is the nurse’s priority intervention?
A) Maintain a patent airway
B) Place the patient in Trendelenburg position
C) Encourage oral fluids
D) Administer opioid pain medication
Correct Answer: A) Maintain a patent airway
Rationale: A GCS score of 6 indicates severe brain injury and impaired consciousness, putting the patient at high risk for airway compromise. Trendelenburg position (B) increases ICP and should be avoided. Encouraging oral fluids (C) is not appropriate due to the risk of aspiration. Opioids (D) can depress respiratory function and should be used cautiously.
The nurse is reviewing arterial blood gas results for a patient with a head injury: pH 7.28, PaCO₂ 52 mmHg, HCO₃ 25 mEq/L, PaO₂ 66 mmHg. What is the most likely effect on the patient’s cerebral blood flow?
A) Vasoconstriction and decreased cerebral blood flow
B) Vasodilation and increased cerebral blood flow
C) No effect on cerebral blood flow
D) Increased resistance in cerebral arteries
Correct Answer: B) Vasodilation and increased cerebral blood flow
Rationale: The patient has respiratory acidosis (pH < 7.35, PaCO₂ > 45 mmHg). High PaCO₂ causes vasodilation of cerebral blood vessels, increasing cerebral blood flow and potentially raising ICP.
The nurse is caring for a patient with a basilar skull fracture. Which assessment finding requires immediate intervention?
A) Clear fluid leaking from the nose
B) Bruising behind the ears
C) A mild headache
D) A Glasgow Coma Scale score of 14
Correct Answer: A) Clear fluid leaking from the nose
Rationale: Clear fluid leakage from the nose (rhinorrhea) may indicate cerebrospinal fluid (CSF) leakage, which increases the risk of meningitis. Battle sign (B) and headache (C) are expected findings but do not require immediate intervention. A GCS score of 14 (D) suggests mild impairment but is not an emergency.
A patient with a head injury is found in decerebrate posturing. The nurse understands that this indicates:
A) Injury to the cerebral cortex
B) Damage to the brainstem
C) Increased ICP but no brain damage
D) An expected reflex response
Correct Answer: B) Damage to the brainstem
Rationale: Decerebrate posturing (arms extended and pronated) is a sign of severe brain injury involving the brainstem. Injury to the cerebral cortex (A) is associated with decorticate posturing (arms flexed). Increased ICP (C) can contribute to posturing, but decerebrate posturing specifically indicates severe brain damage.
The nurse is preparing to administer mannitol to a patient with increased ICP. What is the primary purpose of this medication?
A) Reduce cerebral edema by drawing fluid into the vasculature
B) Lower blood pressure to decrease ICP
C) Decrease cerebrospinal fluid production
D) Constrict cerebral blood vessels
Correct Answer: A) Reduce cerebral edema by drawing fluid into the vasculature
Rationale: Mannitol is an osmotic diuretic that reduces cerebral edema by pulling fluid from brain tissue into the bloodstream for excretion. It does not directly lower blood pressure (B), decrease CSF production (C), or constrict blood vessels (D).
The nurse is teaching a group about concussion management. Which statement by a participant indicates the need for further teaching?
A) “If symptoms last for weeks, it may be post-concussion syndrome.”
B) “I can return to sports as soon as I feel better.”
C) “Rest and avoiding screen time can help with recovery.”
D) “Repeated concussions can increase the risk of brain injury.”
Correct Answer: B) “I can return to sports as soon as I feel better.”
Rationale: Patients should follow a gradual return-to-play protocol and be symptom-free before resuming sports to prevent second impact syndrome. Symptoms lasting for weeks (A) indicate post-concussion syndrome. Rest (C) aids recovery. Repeated concussions (D) increase the risk of long-term brain injury.
A nurse is monitoring a patient with increased intracranial pressure (IICP). Which of the following would be the most concerning finding?
A) A Glasgow Coma Scale (GCS) score of 14
B) A unilateral, fixed, and dilated pupil
C) Complaints of a mild headache
D) A blood pressure of 118/72 mmHg
Correct Answer: B) A unilateral, fixed, and dilated pupil
Rationale: A fixed, dilated pupil (also called a “blown pupil”) is a late and ominous sign of increased ICP, indicating brain herniation. A GCS score of 14 (A) is nearly normal. A mild headache (C) is expected in IICP but not as concerning as pupil changes. A BP of 118/72 mmHg (D) is within normal limits.
A patient with a head injury is being monitored for signs of worsening neurological status. Which vital sign change is most concerning?
A) Heart rate of 102 bpm
B) Respiratory rate of 18 breaths per minute
C) Blood pressure of 180/55 mmHg
D) Temperature of 37.2°C (99°F)
Correct Answer: C) Blood pressure of 180/55 mmHg
Rationale: A widened pulse pressure (high systolic and low diastolic BP) is a sign of Cushing’s triad, which indicates increased ICP and possible brainstem compression. A heart rate of 102 (A) and a normal respiratory rate (B) are less concerning. A temperature of 37.2°C (D) is within normal range.
The nurse is caring for a patient with a basilar skull fracture. What intervention is most appropriate?
A) Insert a nasogastric tube for feeding
B) Encourage frequent nose blowing
C) Monitor for cerebrospinal fluid (CSF) leakage
D) Suction the nasal passage as needed
Correct Answer: C) Monitor for cerebrospinal fluid (CSF) leakage
Rationale: A basilar skull fracture can cause a CSF leak, which increases the risk of infection and meningitis. A nasogastric tube (A) should be avoided due to the risk of penetrating the brain. Nose blowing (B) can worsen the CSF leak. Suctioning (D) should be done with caution to avoid further damage.
A patient with a traumatic brain injury is receiving mechanical ventilation. The nurse notes a PaCO₂ level of 50 mmHg. What is the priority action?
A) Increase the patient’s oxygen flow rate
B) Notify the provider immediately
C) Increase the ventilation rate to lower PaCO₂
D) Position the patient flat to improve oxygenation
Correct Answer: C) Increase the ventilation rate to lower PaCO₂
Rationale: A PaCO₂ level of 50 mmHg indicates hypercapnia, which can lead to cerebral vasodilation and increased ICP. Increasing the ventilation rate helps remove CO₂ and reduce ICP. Increasing oxygen flow (A) does not address CO₂ retention. Notifying the provider (B) is important but not the immediate priority. Positioning the patient flat (D) would worsen ICP.
The nurse is positioning a patient with increased ICP. Which of the following positions is most appropriate?
A) Supine with a flat head of bed
B) Head of bed elevated at 30 degrees with neck in a neutral position
C) Trendelenburg position
D) Side-lying with the head lower than the body
Correct Answer: B) Head of bed elevated at 30 degrees with neck in a neutral position
Rationale: Elevating the HOB to 30 degrees improves venous drainage from the brain, helping to lower ICP. Supine positioning (A) can increase ICP. Trendelenburg (C) increases pressure in the brain. A side-lying position with the head lower (D) can also increase ICP.
A patient with increased intracranial pressure (IICP) is receiving mannitol. Which finding would indicate the medication is effective?
A) Decreased urine output
B) Decreased intracranial pressure readings
C) Increased blood pressure
D) Increased pupillary response time
Correct Answer: B) Decreased intracranial pressure readings
Rationale: Mannitol is an osmotic diuretic that helps reduce cerebral edema and ICP. A decrease in ICP readings confirms its effectiveness. Decreased urine output (A) would indicate dehydration or renal impairment. Increased BP (C) is not the primary goal. Increased pupillary response time (D) suggests worsening neurological function.
The nurse is monitoring a patient with a traumatic brain injury. Which of the following findings suggests brain herniation?
A) Bilateral, equal, and reactive pupils
B) Decreasing level of consciousness
C) Mild headache and nausea
D) Glasgow Coma Scale score of 15
Correct Answer: B) Decreasing level of consciousness
Rationale: A declining level of consciousness is a key sign of brain herniation. Bilateral reactive pupils (A) are normal. A mild headache and nausea (C) are common in head injuries but do not indicate herniation. A GCS score of 15 (D) is a normal neurological finding.
A patient with increased ICP is receiving care in the ICU. Which action by the nurse is inappropriate?
A) Suctioning the airway for 10 seconds when necessary
B) Maintaining a quiet environment with dim lights
C) Administering IV fluids rapidly to maintain blood pressure
D) Monitoring for Cushing’s triad
Correct Answer: C) Administering IV fluids rapidly to maintain blood pressure
Rationale: Rapid IV fluid administration can increase cerebral edema and worsen ICP. Suctioning (A) should be brief to prevent ICP spikes. A quiet, low-stimulation environment (B) helps reduce ICP. Monitoring for Cushing’s triad (D) is essential for early intervention.
A patient with a head injury is diagnosed with an epidural hematoma. The nurse expects which of the following findings?
A) Gradual worsening of symptoms over 48 hours
B) A brief period of unconsciousness followed by lucidity, then rapid decline
C) Slow neurological deterioration over several days
D) Headache and dizziness without significant neurological changes
Correct Answer: B) A brief period of unconsciousness followed by lucidity, then rapid decline
Rationale: Epidural hematomas often present with a “lucid interval” where the patient initially loses consciousness, regains it briefly, and then rapidly deteriorates due to arterial bleeding. Gradual worsening (A, C) is more typical of subdural hematomas. A headache and dizziness (D) alone are not specific to an epidural hematoma.
A patient with increased ICP is prescribed hypertonic saline. The nurse understands that this medication works by:
A) Increasing cerebral blood flow
B) Drawing fluid out of brain tissue to reduce swelling
C) Lowering blood pressure to decrease ICP
D) Blocking pain receptors in the brain
Correct Answer: B) Drawing fluid out of brain tissue to reduce swelling
Rationale: Hypertonic saline creates an osmotic gradient that pulls excess fluid out of brain cells, reducing cerebral edema and ICP. It does not increase cerebral blood flow (A) or lower blood pressure (C) directly. It is not a pain medication (D).
A nurse is assessing a patient with a suspected skull fracture. Which finding suggests a basilar skull fracture?
A) Hematoma over the temporal region
B) Battle sign and raccoon eyes
C) Constricted pupils and photophobia
D) Sudden loss of consciousness
Correct Answer: B) Battle sign and raccoon eyes
Rationale: Battle sign (bruising behind the ears) and raccoon eyes (periorbital ecchymosis) are classic signs of a basilar skull fracture. A hematoma over the temporal region (A) suggests a possible temporal bone fracture. Constricted pupils (C) and loss of consciousness (D) are not specific to basilar skull fractures.
A nurse is monitoring a patient with a head injury. Which of the following indicates a worsening neurological status?
A) Increasing restlessness and confusion
B) Reactive pupils and verbal responsiveness
C) Blood pressure 110/70 mmHg and heart rate 82 bpm
D) Mild headache and dizziness
Correct Answer: A) Increasing restlessness and confusion
Rationale: Altered level of consciousness (LOC), restlessness, and confusion are early signs of increased ICP. Reactive pupils and responsiveness (B) suggest an intact neurological status. BP 110/70 and HR 82 (C) are within normal limits. Mild headache and dizziness (D) may occur but do not necessarily indicate deterioration.
A patient is diagnosed with a subdural hematoma. The nurse understands that this condition is primarily caused by:
A) Arterial bleeding
B) Venous bleeding
C) Skull fracture
D) Brainstem herniation
Correct Answer: B) Venous bleeding
Rationale: Subdural hematomas result from venous bleeding, leading to slower symptom onset. Epidural hematomas (A) involve arterial bleeding. Skull fractures (C) may be associated with head trauma but are not the primary cause. Brainstem herniation (D) is a complication of increased ICP.
A patient with a traumatic brain injury has a Glasgow Coma Scale (GCS) score of 8. The nurse should:
A) Encourage the patient to drink fluids
B) Prepare for possible intubation
C) Assess the patient’s ability to walk
D) Reassess in 8 hours
Correct Answer: B) Prepare for possible intubation
Rationale: A GCS score of 8 or below indicates severe brain injury and a high risk of airway compromise, requiring potential intubation. Encouraging fluids (A) and walking (C) are inappropriate due to the patient’s neurological status. Delayed reassessment (D) is not safe.
A nurse is preparing to administer mannitol to a patient with increased ICP. What should the nurse monitor?
A) Serum potassium levels
B) Blood glucose levels
C) Urine output and serum osmolality
D) Capillary refill time
Correct Answer: C) Urine output and serum osmolality
Rationale: Mannitol is an osmotic diuretic that increases urine output and affects serum osmolality. Monitoring potassium (A) and glucose (B) is important but not the priority. Capillary refill time (D) is unrelated to mannitol therapy.
A nurse is caring for a patient with a head injury. Which of the following are signs of Cushing’s triad? (Select all that apply)
A) Widened pulse pressure
B) Bradycardia
C) Irregular respirations
D) Hypertension with narrowing pulse pressure
E) Tachycardia
Correct Answers: A, B, C
Rationale: Cushing’s triad consists of widened pulse pressure (A), bradycardia (B), and irregular respirations (C) and indicates increased ICP. Narrowing pulse pressure (D) is incorrect. Tachycardia (E) is not part of Cushing’s triad.
The nurse is teaching a patient with a concussion about post-concussion syndrome. Which symptoms should the patient report? (Select all that apply)
A) Headaches
B) Memory problems
C) Difficulty concentrating
D) Sensitivity to light and noise
E) Improved reaction time
Correct Answers: A, B, C, D
Rationale: Post-concussion syndrome includes headaches (A), memory problems (B), difficulty concentrating (C), and sensitivity to light/noise (D). Reaction time (E) worsens, not improves.
A nurse is caring for a patient with increased ICP. Which action should be avoided?
A) Keeping the head midline
B) Frequent suctioning
C) Elevating the head of the bed to 30 degrees
D) Providing a quiet environment
Correct Answer: B) Frequent suctioning
Rationale: Frequent suctioning increases intrathoracic pressure, which raises ICP.
Keeping the head midline (A), elevating the HOB (C), and reducing stimuli (D) are appropriate interventions.
The nurse is educating a patient with a skull fracture. Which statement requires further teaching?
A) “I should avoid activities that could result in another head injury.”
B) “If I notice clear fluid leaking from my nose, I should call my doctor immediately.”
C) “I should take ibuprofen for headaches.”
D) “I should watch for signs of confusion or drowsiness.”
Correct Answer: C) “I should take ibuprofen for headaches.”
Rationale: NSAIDs like ibuprofen increase the risk of bleeding and should be avoided. Patients should report CSF leakage (B), monitor for neurological changes (D), and avoid re-injury (A).
A nurse is reviewing a patient’s arterial blood gas (ABG) results: pH 7.30, PaCO₂ 50 mmHg, HCO₃ 24. How will this affect cerebral blood flow?
A) Vasodilation and increased blood flow
B) Vasoconstriction and reduced blood flow
C) No change in blood flow
D) Increased ICP with reduced cerebral perfusion
Correct Answer: A) Vasodilation and increased blood flow
Rationale: High PaCO₂ causes vasodilation, increasing cerebral blood flow and ICP.
A patient with a head injury is being assessed using the Glasgow Coma Scale (GCS). Which components are evaluated? (Select all that apply)
A) Eye opening
B) Verbal response
C) Motor response
D) Reflexes
E) Pupillary reaction
Correct Answers: A, B, C
Rationale: The GCS assesses eye opening (A), verbal response (B), and motor response (C). Reflexes (D) and pupillary reaction (E) are not included in the GCS.
The nurse is providing care for a patient with increased ICP. Which interventions are appropriate? (Select all that apply)
A) Maintain normothermia
B) Administer IV fluids cautiously
C) Monitor for signs of herniation
D) Keep the head and neck in a neutral position
E) Encourage Valsalva maneuver
Correct Answers: A, B, C, D
Rationale: Managing ICP includes maintaining normothermia (A), careful IV fluid use (B), monitoring for herniation (C), and keeping the head neutral (D). The Valsalva maneuver (E) should be avoided as it increases ICP.
