TRAUMA NURSE SPECIALIST (TNS) CERTIFICATION
EXAM PRACTICE QUESTIONS: TRAUMATIC BRAIN
INJURY 100% CORRECT!
Table of Contents
● Section 1: Questions 1–30
● Answer Key
● High-Yield Review
Section 1: Questions 1–30
Question 1.
A 34-year-old construction worker is admitted to the emergency department following a fall from
a scaffold. He is intubated and mechanically ventilated. His initial Glasgow Coma Scale (GCS)
score is 7 ($E_1V_T M_5$). Over the last hour, his blood pressure increases from 120/70
mmHg to 178/92 mmHg, his heart rate drops from 88 beats/min to 54 beats/min, and his
respiratory pattern becomes irregular. Which of the following pathophysiological processes is
most likely occurring?
A. Spinal shock secondary to an unmasked cervical spinal cord injury
B. Hypovolemic shock resulting from internal hemorrhage and decreased cardiac preload
C. Neurogenic shock caused by loss of sympathetic tone below the level of the brainstem lesion
D. Cushing's triad indicative of acute intracranial hypertension and impending brainstem
herniation
Correct Answer: D. Cushing's triad indicative of acute intracranial hypertension and impending
brainstem herniation
Rationale:
1. Why the correct answer is best: Cushing's triad consists of widening pulse pressure
(systolic hypertension), bradycardia, and irregular respirations. This classic late sign
indicates critical elevation of intracranial pressure (ICP) causing brainstem compression
and impending herniation.
2. Why each incorrect option is less appropriate:
○ Option A causes hypotension and bradycardia, not hypertension.
○ Option B causes tachycardia and hypotension, not hypertension and bradycardia.
○ Option C causes profound hypotension and warm, dry skin due to loss of
sympathetic tone, not hypertension.
, 3. Key trauma-care principle: Recognizing the triad of Cushing's response as a
life-threatening indicator of uncompensated intracranial hypertension requiring
immediate decompression strategies.
Question 2.
An adult male involved in a high-speed motor vehicle collision presents with an acute subdural
hematoma and a midline shift of 8 mm on computed tomography (CT). He is sedated,
paralyzed, and mechanically ventilated. The intracranial pressure (ICP) monitor reads 24
mmHg, and the mean arterial pressure (MAP) is 85 mmHg. Which of the following is the primary
physiological calculation and goal for this patient?
A. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which is below the target
threshold of 60–70 mmHg and requires immediate optimization.
B. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which falls within the
acceptable therapeutic target range of 60–70 mmHg for adult TBI.
C. Calculate the Cerebral Perfusion Pressure (CPP) as 109 mmHg, which requires emergent
administration of loop diuretics to lower cerebral blood volume.
D. Calculate the Cerebral Perfusion Pressure (CPP) as 109 mmHg, which is within normal
physiological limits for a normotensive trauma patient.
Correct Answer: B. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which falls
within the acceptable therapeutic target range of 60–70 mmHg for adult TBI.
Rationale:
1. Why the correct answer is best: CPP is calculated as MAP minus ICP ($85 - 24 = 61$
mmHg). Brain Trauma Foundation guidelines recommend maintaining CPP between 60
and 70 mmHg to balance tissue perfusion with the risk of hyperemic secondary injury.
2. Why each incorrect option is less appropriate:
○ Option A is incorrect because 61 mmHg is inside, not below, the target range
(though near the lower bound, it meets the standard 60–70 mmHg window).
○ Options C and D use incorrect arithmetic ($85 + 24$) or misinterpret the
acceptable target parameters.
3. Key trauma-care principle: Accurately calculating and continuously monitoring
Cerebral Perfusion Pressure ($CPP = MAP - ICP$) to guide fluid resuscitation and
vasoactive therapy in severe TBI.
Question 3.
A 22-year-old female is admitted after being struck by a car. She opens her eyes to pain, makes
incomprehensible sounds, and localizes to painful stimuli. Her right pupil is 6 mm and
nonreactive; her left pupil is 3 mm and briskly reactive. What is her GCS score, and what is the
clinical significance of her pupillary exam?
, A. GCS 9; the right fixed and dilated pupil suggests ipsilateral uncal herniation due to
oculomotor nerve compression.
B. GCS 7; the right fixed and dilated pupil suggests contralateral cerebral hemispheric damage.
C. GCS 9; the left fixed and dilated pupil suggests contralateral third nerve palsy.
D. GCS 7; the right fixed and dilated pupil suggests brainstem death without focal pathology.
Correct Answer: A. GCS 9; the right fixed and dilated pupil suggests ipsilateral uncal herniation
due to oculomotor nerve compression.
Rationale:
1. Why the correct answer is best: GCS score calculation: Eye opening to pain ($E_2$)
+ Incomprehensible sounds ($V_2$) + Localizing to pain ($M_5$) = 9. A dilated,
unreactive pupil on the same side as the intracranial mass effect indicates compression
of cranial nerve III (oculomotor nerve) secondary to uncal herniation.
2. Why each incorrect option is less appropriate:
○ Option B miscalculates the GCS ($2+2+5 = 9$, not 7).
○ Option C incorrectly attributes the pathology to the left pupil.
○ Option D misinterprets the lateralizing sign of a blown pupil, which points to focal
mass effect rather than diffuse brainstem death.
3. Key trauma-care principle: Correlating focal pupillary abnormalities with lateralized
intracranial pathology and accurate GCS scoring during initial neurological evaluation.
Question 4.
A trauma patient with a severe TBI is receiving mechanical ventilation. The trauma team orders
hypertonic saline (3%) to manage a sudden spike in ICP to 28 mmHg. Which of the following is
the primary mechanism of action of hypertonic saline in reducing intracranial pressure?
A. Inducing systemic vasodilation to decrease total circulating blood volume and lower central
venous pressure.
B. Creating an osmotic gradient that draws water from the intracellular and interstitial spaces of
the brain into the intravascular space.
C. Binding to cerebral osmotic receptors to permanently block cerebrospinal fluid production at
the choroid plexus.
D. Decreasing metabolic demand of injured neurons by blocking sodium-potassium adenosine
triphosphatase pumps.
Correct Answer: B. Creating an osmotic gradient that draws water from the intracellular and
interstitial spaces of the brain into the intravascular space.
EXAM PRACTICE QUESTIONS: TRAUMATIC BRAIN
INJURY 100% CORRECT!
Table of Contents
● Section 1: Questions 1–30
● Answer Key
● High-Yield Review
Section 1: Questions 1–30
Question 1.
A 34-year-old construction worker is admitted to the emergency department following a fall from
a scaffold. He is intubated and mechanically ventilated. His initial Glasgow Coma Scale (GCS)
score is 7 ($E_1V_T M_5$). Over the last hour, his blood pressure increases from 120/70
mmHg to 178/92 mmHg, his heart rate drops from 88 beats/min to 54 beats/min, and his
respiratory pattern becomes irregular. Which of the following pathophysiological processes is
most likely occurring?
A. Spinal shock secondary to an unmasked cervical spinal cord injury
B. Hypovolemic shock resulting from internal hemorrhage and decreased cardiac preload
C. Neurogenic shock caused by loss of sympathetic tone below the level of the brainstem lesion
D. Cushing's triad indicative of acute intracranial hypertension and impending brainstem
herniation
Correct Answer: D. Cushing's triad indicative of acute intracranial hypertension and impending
brainstem herniation
Rationale:
1. Why the correct answer is best: Cushing's triad consists of widening pulse pressure
(systolic hypertension), bradycardia, and irregular respirations. This classic late sign
indicates critical elevation of intracranial pressure (ICP) causing brainstem compression
and impending herniation.
2. Why each incorrect option is less appropriate:
○ Option A causes hypotension and bradycardia, not hypertension.
○ Option B causes tachycardia and hypotension, not hypertension and bradycardia.
○ Option C causes profound hypotension and warm, dry skin due to loss of
sympathetic tone, not hypertension.
, 3. Key trauma-care principle: Recognizing the triad of Cushing's response as a
life-threatening indicator of uncompensated intracranial hypertension requiring
immediate decompression strategies.
Question 2.
An adult male involved in a high-speed motor vehicle collision presents with an acute subdural
hematoma and a midline shift of 8 mm on computed tomography (CT). He is sedated,
paralyzed, and mechanically ventilated. The intracranial pressure (ICP) monitor reads 24
mmHg, and the mean arterial pressure (MAP) is 85 mmHg. Which of the following is the primary
physiological calculation and goal for this patient?
A. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which is below the target
threshold of 60–70 mmHg and requires immediate optimization.
B. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which falls within the
acceptable therapeutic target range of 60–70 mmHg for adult TBI.
C. Calculate the Cerebral Perfusion Pressure (CPP) as 109 mmHg, which requires emergent
administration of loop diuretics to lower cerebral blood volume.
D. Calculate the Cerebral Perfusion Pressure (CPP) as 109 mmHg, which is within normal
physiological limits for a normotensive trauma patient.
Correct Answer: B. Calculate the Cerebral Perfusion Pressure (CPP) as 61 mmHg, which falls
within the acceptable therapeutic target range of 60–70 mmHg for adult TBI.
Rationale:
1. Why the correct answer is best: CPP is calculated as MAP minus ICP ($85 - 24 = 61$
mmHg). Brain Trauma Foundation guidelines recommend maintaining CPP between 60
and 70 mmHg to balance tissue perfusion with the risk of hyperemic secondary injury.
2. Why each incorrect option is less appropriate:
○ Option A is incorrect because 61 mmHg is inside, not below, the target range
(though near the lower bound, it meets the standard 60–70 mmHg window).
○ Options C and D use incorrect arithmetic ($85 + 24$) or misinterpret the
acceptable target parameters.
3. Key trauma-care principle: Accurately calculating and continuously monitoring
Cerebral Perfusion Pressure ($CPP = MAP - ICP$) to guide fluid resuscitation and
vasoactive therapy in severe TBI.
Question 3.
A 22-year-old female is admitted after being struck by a car. She opens her eyes to pain, makes
incomprehensible sounds, and localizes to painful stimuli. Her right pupil is 6 mm and
nonreactive; her left pupil is 3 mm and briskly reactive. What is her GCS score, and what is the
clinical significance of her pupillary exam?
, A. GCS 9; the right fixed and dilated pupil suggests ipsilateral uncal herniation due to
oculomotor nerve compression.
B. GCS 7; the right fixed and dilated pupil suggests contralateral cerebral hemispheric damage.
C. GCS 9; the left fixed and dilated pupil suggests contralateral third nerve palsy.
D. GCS 7; the right fixed and dilated pupil suggests brainstem death without focal pathology.
Correct Answer: A. GCS 9; the right fixed and dilated pupil suggests ipsilateral uncal herniation
due to oculomotor nerve compression.
Rationale:
1. Why the correct answer is best: GCS score calculation: Eye opening to pain ($E_2$)
+ Incomprehensible sounds ($V_2$) + Localizing to pain ($M_5$) = 9. A dilated,
unreactive pupil on the same side as the intracranial mass effect indicates compression
of cranial nerve III (oculomotor nerve) secondary to uncal herniation.
2. Why each incorrect option is less appropriate:
○ Option B miscalculates the GCS ($2+2+5 = 9$, not 7).
○ Option C incorrectly attributes the pathology to the left pupil.
○ Option D misinterprets the lateralizing sign of a blown pupil, which points to focal
mass effect rather than diffuse brainstem death.
3. Key trauma-care principle: Correlating focal pupillary abnormalities with lateralized
intracranial pathology and accurate GCS scoring during initial neurological evaluation.
Question 4.
A trauma patient with a severe TBI is receiving mechanical ventilation. The trauma team orders
hypertonic saline (3%) to manage a sudden spike in ICP to 28 mmHg. Which of the following is
the primary mechanism of action of hypertonic saline in reducing intracranial pressure?
A. Inducing systemic vasodilation to decrease total circulating blood volume and lower central
venous pressure.
B. Creating an osmotic gradient that draws water from the intracellular and interstitial spaces of
the brain into the intravascular space.
C. Binding to cerebral osmotic receptors to permanently block cerebrospinal fluid production at
the choroid plexus.
D. Decreasing metabolic demand of injured neurons by blocking sodium-potassium adenosine
triphosphatase pumps.
Correct Answer: B. Creating an osmotic gradient that draws water from the intracellular and
interstitial spaces of the brain into the intravascular space.
