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Nursing 354 Traumatic Brain Injury
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
___________________________________________________________________
1. A patient arrives after a motor vehicle collision with suspected traumatic
brain injury (TBI). Which assessment finding requires the nurse's immediate
attention?
A. Mild headache
B. Unequal pupils
C. Scalp tenderness
D. Nausea
Answer: Unequal pupils
Rationale: Unequal pupils may indicate increasing intracranial pressure, cerebral
herniation, or focal neurologic injury and requires immediate evaluation.
2. Which Glasgow Coma Scale (GCS) score represents the most severe
impairment of consciousness?
A. 15
B. 12
C. 8
D. 10
,Answer: 8
Rationale: The Glasgow Coma Scale ranges from 3 to 15, with lower scores
indicating greater impairment. A score of 8 or less is generally considered severe
neurologic impairment and may indicate the need for airway protection.
3. A patient with a severe TBI has a Glasgow Coma Scale score of 6. Which
intervention should the nurse anticipate?
A. Oral fluids
B. Airway protection
C. Ambulation
D. Routine discharge
Answer: Airway protection
Rationale: A severely decreased level of consciousness places the patient at high
risk for loss of airway protective reflexes and aspiration. Airway management is
a priority.
4. Which finding is most concerning for increased intracranial pressure?
A. Bradycardia with hypertension
B. Tachycardia with hypotension
C. Fever with tachypnea
D. Mild hypertension with anxiety
Answer: Bradycardia with hypertension
Rationale: Bradycardia, hypertension, and abnormal respirations constitute
Cushing's response, a late sign of significantly increased intracranial pressure.
5. Which position is generally appropriate for a patient with increased
intracranial pressure, assuming no contraindication?
A. Flat with legs elevated
B. Head of bed elevated approximately 30 degrees
C. Trendelenburg position
D. Prone position
,Answer: Head of bed elevated approximately 30 degrees
Rationale: Elevating the head of the bed while maintaining neutral head and
neck alignment can promote cerebral venous drainage and help reduce
intracranial pressure.
6. A nurse is assessing a patient after a head injury. Which finding suggests a
basilar skull fracture?
A. Bruising around the eyes
B. Superficial scalp abrasion
C. Mild facial swelling
D. Small forehead laceration
Answer: Bruising around the eyes
Rationale: Periorbital ecchymosis, sometimes called raccoon eyes, may occur
with a basilar skull fracture.
7. Which finding may indicate a cerebrospinal fluid (CSF) leak following head
trauma?
A. Clear drainage from the nose
B. Thick yellow sputum
C. Bloody urine
D. Excessive sweating
Answer: Clear drainage from the nose
Rationale: Clear drainage from the nose or ear after head trauma may represent
CSF and requires prompt evaluation because of the risk for intracranial infection.
8. A patient with a suspected CSF leak has clear drainage from the ear. Which
action should the nurse take?
A. Insert a cotton swab into the ear
B. Pack the ear tightly
C. Allow the drainage to flow and notify the provider
D. Irrigate the ear
, Answer: Allow the drainage to flow and notify the provider
Rationale: CSF drainage should not be obstructed, packed, or irrigated. The
finding should be reported promptly.
9. Which assessment is most important when monitoring a patient with a
traumatic brain injury?
A. Neurologic status
B. Skin turgor
C. Bowel sounds
D. Appetite
Answer: Neurologic status
Rationale: Frequent neurologic assessment helps detect deterioration,
increasing intracranial pressure, cerebral edema, and other complications early.
10.Which change in level of consciousness is most concerning in a patient with
TBI?
A. Becoming increasingly difficult to arouse
B. Asking repeated questions
C. Reporting a mild headache
D. Sleeping after receiving pain medication
Answer: Becoming increasingly difficult to arouse
Rationale: A declining level of consciousness is an important indicator of
neurologic deterioration and may reflect increasing intracranial pressure or
expanding intracranial injury.
11.Which type of intracranial hemorrhage is located between the skull and
dura mater?
A. Subarachnoid hemorrhage
B. Epidural hematoma
C. Subdural hematoma
D. Intracerebral hemorrhage
Nursing 354 Traumatic Brain Injury
Exam Questions And Correct Answers
(Verified Answers) Plus Rationales 2026
Q&A Instant Download Pdf
___________________________________________________________________
1. A patient arrives after a motor vehicle collision with suspected traumatic
brain injury (TBI). Which assessment finding requires the nurse's immediate
attention?
A. Mild headache
B. Unequal pupils
C. Scalp tenderness
D. Nausea
Answer: Unequal pupils
Rationale: Unequal pupils may indicate increasing intracranial pressure, cerebral
herniation, or focal neurologic injury and requires immediate evaluation.
2. Which Glasgow Coma Scale (GCS) score represents the most severe
impairment of consciousness?
A. 15
B. 12
C. 8
D. 10
,Answer: 8
Rationale: The Glasgow Coma Scale ranges from 3 to 15, with lower scores
indicating greater impairment. A score of 8 or less is generally considered severe
neurologic impairment and may indicate the need for airway protection.
3. A patient with a severe TBI has a Glasgow Coma Scale score of 6. Which
intervention should the nurse anticipate?
A. Oral fluids
B. Airway protection
C. Ambulation
D. Routine discharge
Answer: Airway protection
Rationale: A severely decreased level of consciousness places the patient at high
risk for loss of airway protective reflexes and aspiration. Airway management is
a priority.
4. Which finding is most concerning for increased intracranial pressure?
A. Bradycardia with hypertension
B. Tachycardia with hypotension
C. Fever with tachypnea
D. Mild hypertension with anxiety
Answer: Bradycardia with hypertension
Rationale: Bradycardia, hypertension, and abnormal respirations constitute
Cushing's response, a late sign of significantly increased intracranial pressure.
5. Which position is generally appropriate for a patient with increased
intracranial pressure, assuming no contraindication?
A. Flat with legs elevated
B. Head of bed elevated approximately 30 degrees
C. Trendelenburg position
D. Prone position
,Answer: Head of bed elevated approximately 30 degrees
Rationale: Elevating the head of the bed while maintaining neutral head and
neck alignment can promote cerebral venous drainage and help reduce
intracranial pressure.
6. A nurse is assessing a patient after a head injury. Which finding suggests a
basilar skull fracture?
A. Bruising around the eyes
B. Superficial scalp abrasion
C. Mild facial swelling
D. Small forehead laceration
Answer: Bruising around the eyes
Rationale: Periorbital ecchymosis, sometimes called raccoon eyes, may occur
with a basilar skull fracture.
7. Which finding may indicate a cerebrospinal fluid (CSF) leak following head
trauma?
A. Clear drainage from the nose
B. Thick yellow sputum
C. Bloody urine
D. Excessive sweating
Answer: Clear drainage from the nose
Rationale: Clear drainage from the nose or ear after head trauma may represent
CSF and requires prompt evaluation because of the risk for intracranial infection.
8. A patient with a suspected CSF leak has clear drainage from the ear. Which
action should the nurse take?
A. Insert a cotton swab into the ear
B. Pack the ear tightly
C. Allow the drainage to flow and notify the provider
D. Irrigate the ear
, Answer: Allow the drainage to flow and notify the provider
Rationale: CSF drainage should not be obstructed, packed, or irrigated. The
finding should be reported promptly.
9. Which assessment is most important when monitoring a patient with a
traumatic brain injury?
A. Neurologic status
B. Skin turgor
C. Bowel sounds
D. Appetite
Answer: Neurologic status
Rationale: Frequent neurologic assessment helps detect deterioration,
increasing intracranial pressure, cerebral edema, and other complications early.
10.Which change in level of consciousness is most concerning in a patient with
TBI?
A. Becoming increasingly difficult to arouse
B. Asking repeated questions
C. Reporting a mild headache
D. Sleeping after receiving pain medication
Answer: Becoming increasingly difficult to arouse
Rationale: A declining level of consciousness is an important indicator of
neurologic deterioration and may reflect increasing intracranial pressure or
expanding intracranial injury.
11.Which type of intracranial hemorrhage is located between the skull and
dura mater?
A. Subarachnoid hemorrhage
B. Epidural hematoma
C. Subdural hematoma
D. Intracerebral hemorrhage
