NUR 2755 IV EXAM 3 FINAL: NEUROLOGY AND
TRAUMA QUESTIONS AND ANSWERS | 2026
UPDATE | WITH COMPLETE SOLUTIONS.
1. A patient with severe traumatic brain injury (TBI) has an intracranial pressure (ICP) of 28 mm
Hg and cerebral perfusion pressure (CPP) of 50 mm Hg despite sedation and head-of-bed
elevation. The mean arterial pressure (MAP) is 78 mm Hg. Which intervention should the nurse
anticipate as the next priority to optimize cerebral perfusion while avoiding further ICP elevation?
A. Administer mannitol 0.5 g/kg IV bolus
B. Initiate therapeutic hypothermia to 32-34°C
C. Administer norepinephrine to raise MAP to 90 mm Hg
D. Perform a decompressive craniectomy
Answer: C
Rationale: With CPP = MAP - ICP, the current CPP of 50 is below the target (60-70 mm Hg). Raising
MAP with vasopressors (norepinephrine) increases CPP without directly increasing ICP. Mannitol may
reduce ICP but can cause hypovolemia and further lower MAP. Hypothermia is not immediate.
Craniectomy is reserved for refractory ICP elevation.
2. A patient with a C6 spinal cord injury develops sudden onset of severe headache, diaphoresis
above the level of injury, and bradycardia. Blood pressure is 220/110 mm Hg. Which
pathophysiological mechanism is primarily responsible for this phenomenon?
A. Uninhibited parasympathetic outflow from the vagus nerve
B. Loss of descending inhibitory control of spinal sympathetic neurons below the lesion
C. Increased baroreceptor sensitivity due to carotid sinus denervation
D. Massive release of catecholamines from the adrenal medulla
Answer: B
Rationale: Autonomic dysreflexia occurs in spinal cord injury above T6. A noxious stimulus below the
lesion triggers a reflex sympathetic surge, but descending inhibitory pathways from the brain are
interrupted, leading to unchecked vasoconstriction and hypertension. Baroreceptors detect hypertension
and trigger bradycardia via vagus, but the primary mechanism is loss of descending inhibition.
3. In a patient with acute ischemic stroke undergoing mechanical thrombectomy, which of the
following findings on computed tomography perfusion (CTP) imaging is most strongly associated
with a favorable outcome after reperfusion?
A. Large core infarct with matched perfusion deficit
B. Mismatch ratio of >1.8 between ischemic penumbra and core infarct
C. Absence of any perfusion abnormality
D. Widespread hypodensity involving >1/3 of the middle cerebral artery territory
Page 1
,Answer: B
Rationale: A perfusion-diffusion mismatch indicates salvageable penumbra. A mismatch ratio >1.8 is a
validated criterion for selecting patients likely to benefit from thrombectomy beyond 6 hours. A large
core (option A) or widespread hypodensity (option D) suggests irreversible infarct with poor prognosis.
Absence of abnormality (C) may indicate misdiagnosis or very small stroke.
4. A patient with a suspected basilar skull fracture presents with periorbital ecchymosis and
Battle's sign. Which of the following additional findings would most strongly indicate the need for
prophylactic antibiotics?
A. Hemotympanum
B. CSF rhinorrhea
C. Facial nerve palsy
D. Conductive hearing loss
Answer: B
Rationale: Basilar skull fractures with CSF leak (rhinorrhea or otorrhea) create a direct communication
between the subarachnoid space and the environment, increasing meningitis risk. Prophylactic
antibiotics are controversial but often considered in persistent CSF leaks. Hemotympanum, facial nerve
palsy, and conductive hearing loss are common but do not independently indicate antibiotic need.
5. A patient with a traumatic brain injury has an ICP waveform showing elevated P2 amplitude
relative to P1. This waveform morphology is most consistent with which of the following
intracranial dynamics?
A. Normal cerebral compliance
B. Decreased cerebral compliance
C. Increased cerebral blood flow
D. Cerebral vasospasm
Answer: B
Rationale: The normal ICP waveform has P1 (percussion wave) > P2 (tidal wave). As compliance
decreases, the brain becomes less able to accommodate volume, causing P2 to rise relative to P1 (P2 >
P1). This indicates reduced compensatory reserve and impending intracranial hypertension. Increased
CBF or vasospasm do not directly cause this waveform change.
6. A patient with a spinal cord injury at T4 is being managed with methylprednisolone per the
NASCIS III protocol. The nurse is administering the loading dose 3 hours after injury. Which of
the following is the correct ongoing dosing schedule?
A. 5.4 mg/kg/hr for 23 hours
B. 5.4 mg/kg/hr for 48 hours
C. 4.0 mg/kg/hr for 23 hours
D. 4.0 mg/kg/hr for 48 hours
Answer: A
Rationale: The NASCIS III protocol for methylprednisolone in acute SCI: loading dose of 30 mg/kg over
15 minutes, followed by 5.4 mg/kg/hr for 23 hours if initiated within 3 hours of injury. If initiated 3-8
hours after injury, the infusion continues for 48 hours. The 48-hour schedule is not used for a 3-hour
window. Options C and D are incorrect doses.
Page 2
,7. A patient with a Glasgow Coma Scale (GCS) score of 7 (E1 V2 M4) following a motor vehicle
collision is being evaluated for intracranial hypertension. Which of the following interventions has
the strongest evidence for improving outcomes in this population?
A. Prophylactic hyperventilation to PaCO2 of 30 mm Hg
B. Maintenance of cerebral perfusion pressure between 60-70 mm Hg
C. Routine administration of corticosteroids
D. Induced hypothermia to 33°C for 72 hours
Answer: B
Rationale: Current Brain Trauma Foundation guidelines recommend targeting CPP 60-70 mm Hg to
optimize cerebral perfusion while avoiding hyperemia. Prophylactic hyperventilation is harmful (causes
vasoconstriction and ischemia). Corticosteroids are contraindicated in TBI (increased mortality).
Hypothermia is not routinely recommended due to lack of benefit in multicenter trials.
8. A patient with a subarachnoid hemorrhage from a ruptured aneurysm develops delayed
cerebral ischemia. Which of the following interventions is most likely to reduce the risk of cerebral
vasospasm?
A. Intravenous nimodipine
B. Intra-arterial verapamil
C. Therapeutic hypothermia
D. Induced hypertension with phenylephrine
Answer: A
Rationale: Nimodipine, a calcium channel blocker, is the only medication shown to improve neurological
outcomes after aneurysmal SAH, likely by reducing vasospasm and microvascular ischemia.
Intra-arterial verapamil is used for refractory vasospasm but not as prophylaxis. Induced hypertension
is a rescue therapy. Hypothermia has no proven benefit for vasospasm prevention.
9. A patient with a traumatic brain injury has a serum sodium of 155 mEq/L, urine osmolality of
800 mOsm/kg, and central venous pressure of 4 mm Hg. The nurse suspects diabetes insipidus.
Which of the following additional findings would confirm the diagnosis?
A. Urine specific gravity <1.005
B. Serum osmolality <285 mOsm/kg
C. Positive fluid balance over 24 hours
D. Elevated antidiuretic hormone levels
Answer: A
Rationale: Diabetes insipidus (DI) results in dilute urine despite hyperosmolality. Urine specific gravity
<1.005 indicates dilute urine. Serum osmolality is high (>295), not low. Fluid balance is negative due to
polyuria. ADH levels are low in central DI. The combination of hypernatremia, high serum osmolality,
and low urine osmolality/specific gravity is diagnostic.
10. A patient with a C5 spinal cord injury is being weaned from mechanical ventilation. Which of
the following respiratory parameters would most accurately reflect the patient's ability to maintain
adequate ventilation without support?
Page 3
, A. Negative inspiratory force (NIF) of -25 cm H2O
B. Vital capacity (VC) of 15 mL/kg
C. Minute ventilation of 10 L/min
D. Tidal volume of 8 mL/kg
Answer: B
Rationale: Vital capacity is the best predictor of weaning success in cervical SCI. A VC of 15 mL/kg or
more indicates sufficient respiratory muscle strength to clear secretions and sustain ventilation. NIF <
-20 cm H2O is needed but not as sensitive. Minute ventilation and tidal volume can be maintained with
high respiratory rates and may not reflect endurance.
11. A patient with a history of severe traumatic brain injury (TBI) presents with persistent
hypersomnia, cognitive deficits, and autonomic instability. Recent polysomnography reveals a
mean sleep latency of 4 minutes on the Multiple Sleep Latency Test (MSLT) with no sleep-onset
REM periods. Cerebrospinal fluid orexin-A levels are normal. Which of the following
pathophysiological mechanisms most likely underlies this patient's condition?
A. Selective loss of orexinergic neurons in the lateral hypothalamus
B. Dysfunction of the ascending reticular activating system (ARAS) due to axonal injury
C. Autoimmune destruction of hypocretin receptors in the basal forebrain
D. Secondary narcolepsy due to hypothalamic-pituitary axis disruption
Answer: B
Rationale: The normal CSF orexin-A levels rule out orexin deficiency (narcolepsy type 1). TBI often
causes diffuse axonal injury, which can disrupt the ARAS, leading to hypersomnia without cataplexy or
SOREMs. Option A is incorrect because orexin loss would cause low CSF orexin. Option C is not a
typical TBI mechanism. Option D is not supported by the normal orexin levels.
12. A research study investigates a novel neuroprotective agent that inhibits the NLRP3
inflammasome in microglia. In a mouse model of spinal cord injury, treatment reduces lesion size
and improves motor recovery. Which of the following downstream effects is most likely responsible
for the observed benefit?
A. Increased production of interleukin-1² (IL-1²) and IL-18
B. Enhanced pyroptosis of damaged neurons
C. Decreased release of high-mobility group box 1 (HMGB1) and reactive oxygen species
D. Upregulation of caspase-1 activity in microglia
Answer: C
Rationale: NLRP3 inflammasome inhibition reduces microglial activation and subsequent release of
pro-inflammatory mediators like HMGB1 and ROS, which exacerbate secondary injury. Option A is
opposite; inflammasome activation increases IL-1²/IL-18. Option B is incorrect because pyroptosis is a
pro-inflammatory cell death that would worsen injury. Option D is opposite; caspase-1 is activated by
the inflammasome.
Page 4
TRAUMA QUESTIONS AND ANSWERS | 2026
UPDATE | WITH COMPLETE SOLUTIONS.
1. A patient with severe traumatic brain injury (TBI) has an intracranial pressure (ICP) of 28 mm
Hg and cerebral perfusion pressure (CPP) of 50 mm Hg despite sedation and head-of-bed
elevation. The mean arterial pressure (MAP) is 78 mm Hg. Which intervention should the nurse
anticipate as the next priority to optimize cerebral perfusion while avoiding further ICP elevation?
A. Administer mannitol 0.5 g/kg IV bolus
B. Initiate therapeutic hypothermia to 32-34°C
C. Administer norepinephrine to raise MAP to 90 mm Hg
D. Perform a decompressive craniectomy
Answer: C
Rationale: With CPP = MAP - ICP, the current CPP of 50 is below the target (60-70 mm Hg). Raising
MAP with vasopressors (norepinephrine) increases CPP without directly increasing ICP. Mannitol may
reduce ICP but can cause hypovolemia and further lower MAP. Hypothermia is not immediate.
Craniectomy is reserved for refractory ICP elevation.
2. A patient with a C6 spinal cord injury develops sudden onset of severe headache, diaphoresis
above the level of injury, and bradycardia. Blood pressure is 220/110 mm Hg. Which
pathophysiological mechanism is primarily responsible for this phenomenon?
A. Uninhibited parasympathetic outflow from the vagus nerve
B. Loss of descending inhibitory control of spinal sympathetic neurons below the lesion
C. Increased baroreceptor sensitivity due to carotid sinus denervation
D. Massive release of catecholamines from the adrenal medulla
Answer: B
Rationale: Autonomic dysreflexia occurs in spinal cord injury above T6. A noxious stimulus below the
lesion triggers a reflex sympathetic surge, but descending inhibitory pathways from the brain are
interrupted, leading to unchecked vasoconstriction and hypertension. Baroreceptors detect hypertension
and trigger bradycardia via vagus, but the primary mechanism is loss of descending inhibition.
3. In a patient with acute ischemic stroke undergoing mechanical thrombectomy, which of the
following findings on computed tomography perfusion (CTP) imaging is most strongly associated
with a favorable outcome after reperfusion?
A. Large core infarct with matched perfusion deficit
B. Mismatch ratio of >1.8 between ischemic penumbra and core infarct
C. Absence of any perfusion abnormality
D. Widespread hypodensity involving >1/3 of the middle cerebral artery territory
Page 1
,Answer: B
Rationale: A perfusion-diffusion mismatch indicates salvageable penumbra. A mismatch ratio >1.8 is a
validated criterion for selecting patients likely to benefit from thrombectomy beyond 6 hours. A large
core (option A) or widespread hypodensity (option D) suggests irreversible infarct with poor prognosis.
Absence of abnormality (C) may indicate misdiagnosis or very small stroke.
4. A patient with a suspected basilar skull fracture presents with periorbital ecchymosis and
Battle's sign. Which of the following additional findings would most strongly indicate the need for
prophylactic antibiotics?
A. Hemotympanum
B. CSF rhinorrhea
C. Facial nerve palsy
D. Conductive hearing loss
Answer: B
Rationale: Basilar skull fractures with CSF leak (rhinorrhea or otorrhea) create a direct communication
between the subarachnoid space and the environment, increasing meningitis risk. Prophylactic
antibiotics are controversial but often considered in persistent CSF leaks. Hemotympanum, facial nerve
palsy, and conductive hearing loss are common but do not independently indicate antibiotic need.
5. A patient with a traumatic brain injury has an ICP waveform showing elevated P2 amplitude
relative to P1. This waveform morphology is most consistent with which of the following
intracranial dynamics?
A. Normal cerebral compliance
B. Decreased cerebral compliance
C. Increased cerebral blood flow
D. Cerebral vasospasm
Answer: B
Rationale: The normal ICP waveform has P1 (percussion wave) > P2 (tidal wave). As compliance
decreases, the brain becomes less able to accommodate volume, causing P2 to rise relative to P1 (P2 >
P1). This indicates reduced compensatory reserve and impending intracranial hypertension. Increased
CBF or vasospasm do not directly cause this waveform change.
6. A patient with a spinal cord injury at T4 is being managed with methylprednisolone per the
NASCIS III protocol. The nurse is administering the loading dose 3 hours after injury. Which of
the following is the correct ongoing dosing schedule?
A. 5.4 mg/kg/hr for 23 hours
B. 5.4 mg/kg/hr for 48 hours
C. 4.0 mg/kg/hr for 23 hours
D. 4.0 mg/kg/hr for 48 hours
Answer: A
Rationale: The NASCIS III protocol for methylprednisolone in acute SCI: loading dose of 30 mg/kg over
15 minutes, followed by 5.4 mg/kg/hr for 23 hours if initiated within 3 hours of injury. If initiated 3-8
hours after injury, the infusion continues for 48 hours. The 48-hour schedule is not used for a 3-hour
window. Options C and D are incorrect doses.
Page 2
,7. A patient with a Glasgow Coma Scale (GCS) score of 7 (E1 V2 M4) following a motor vehicle
collision is being evaluated for intracranial hypertension. Which of the following interventions has
the strongest evidence for improving outcomes in this population?
A. Prophylactic hyperventilation to PaCO2 of 30 mm Hg
B. Maintenance of cerebral perfusion pressure between 60-70 mm Hg
C. Routine administration of corticosteroids
D. Induced hypothermia to 33°C for 72 hours
Answer: B
Rationale: Current Brain Trauma Foundation guidelines recommend targeting CPP 60-70 mm Hg to
optimize cerebral perfusion while avoiding hyperemia. Prophylactic hyperventilation is harmful (causes
vasoconstriction and ischemia). Corticosteroids are contraindicated in TBI (increased mortality).
Hypothermia is not routinely recommended due to lack of benefit in multicenter trials.
8. A patient with a subarachnoid hemorrhage from a ruptured aneurysm develops delayed
cerebral ischemia. Which of the following interventions is most likely to reduce the risk of cerebral
vasospasm?
A. Intravenous nimodipine
B. Intra-arterial verapamil
C. Therapeutic hypothermia
D. Induced hypertension with phenylephrine
Answer: A
Rationale: Nimodipine, a calcium channel blocker, is the only medication shown to improve neurological
outcomes after aneurysmal SAH, likely by reducing vasospasm and microvascular ischemia.
Intra-arterial verapamil is used for refractory vasospasm but not as prophylaxis. Induced hypertension
is a rescue therapy. Hypothermia has no proven benefit for vasospasm prevention.
9. A patient with a traumatic brain injury has a serum sodium of 155 mEq/L, urine osmolality of
800 mOsm/kg, and central venous pressure of 4 mm Hg. The nurse suspects diabetes insipidus.
Which of the following additional findings would confirm the diagnosis?
A. Urine specific gravity <1.005
B. Serum osmolality <285 mOsm/kg
C. Positive fluid balance over 24 hours
D. Elevated antidiuretic hormone levels
Answer: A
Rationale: Diabetes insipidus (DI) results in dilute urine despite hyperosmolality. Urine specific gravity
<1.005 indicates dilute urine. Serum osmolality is high (>295), not low. Fluid balance is negative due to
polyuria. ADH levels are low in central DI. The combination of hypernatremia, high serum osmolality,
and low urine osmolality/specific gravity is diagnostic.
10. A patient with a C5 spinal cord injury is being weaned from mechanical ventilation. Which of
the following respiratory parameters would most accurately reflect the patient's ability to maintain
adequate ventilation without support?
Page 3
, A. Negative inspiratory force (NIF) of -25 cm H2O
B. Vital capacity (VC) of 15 mL/kg
C. Minute ventilation of 10 L/min
D. Tidal volume of 8 mL/kg
Answer: B
Rationale: Vital capacity is the best predictor of weaning success in cervical SCI. A VC of 15 mL/kg or
more indicates sufficient respiratory muscle strength to clear secretions and sustain ventilation. NIF <
-20 cm H2O is needed but not as sensitive. Minute ventilation and tidal volume can be maintained with
high respiratory rates and may not reflect endurance.
11. A patient with a history of severe traumatic brain injury (TBI) presents with persistent
hypersomnia, cognitive deficits, and autonomic instability. Recent polysomnography reveals a
mean sleep latency of 4 minutes on the Multiple Sleep Latency Test (MSLT) with no sleep-onset
REM periods. Cerebrospinal fluid orexin-A levels are normal. Which of the following
pathophysiological mechanisms most likely underlies this patient's condition?
A. Selective loss of orexinergic neurons in the lateral hypothalamus
B. Dysfunction of the ascending reticular activating system (ARAS) due to axonal injury
C. Autoimmune destruction of hypocretin receptors in the basal forebrain
D. Secondary narcolepsy due to hypothalamic-pituitary axis disruption
Answer: B
Rationale: The normal CSF orexin-A levels rule out orexin deficiency (narcolepsy type 1). TBI often
causes diffuse axonal injury, which can disrupt the ARAS, leading to hypersomnia without cataplexy or
SOREMs. Option A is incorrect because orexin loss would cause low CSF orexin. Option C is not a
typical TBI mechanism. Option D is not supported by the normal orexin levels.
12. A research study investigates a novel neuroprotective agent that inhibits the NLRP3
inflammasome in microglia. In a mouse model of spinal cord injury, treatment reduces lesion size
and improves motor recovery. Which of the following downstream effects is most likely responsible
for the observed benefit?
A. Increased production of interleukin-1² (IL-1²) and IL-18
B. Enhanced pyroptosis of damaged neurons
C. Decreased release of high-mobility group box 1 (HMGB1) and reactive oxygen species
D. Upregulation of caspase-1 activity in microglia
Answer: C
Rationale: NLRP3 inflammasome inhibition reduces microglial activation and subsequent release of
pro-inflammatory mediators like HMGB1 and ROS, which exacerbate secondary injury. Option A is
opposite; inflammasome activation increases IL-1²/IL-18. Option B is incorrect because pyroptosis is a
pro-inflammatory cell death that would worsen injury. Option D is opposite; caspase-1 is activated by
the inflammasome.
Page 4
