USE FIRST NEUROLOGIC TRAUMA MSII EXAMS
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1. A client is brought to the trauma center by ambulance after
sustaining a high cervical spinal cord injury 11/2 hours ago.
Endotracheal intubation has been deemed necessary and the
nurse is preparing to assist. What nursing diagnosis should the
nurse associate with this procedure? A. Risk for impaired skin
integrity B. Risk for injury C. Risk for autonomic dysreflexia D.
Risk for suffocation
ANS: B Rationale: If endotracheal intubation is necessary,
extreme care is taken to avoid flexing or extending the client's
neck, which can result in extension of a cervical injury.
Intubation does not directly cause autonomic dysreflexia and
the threat to skin integrity is not a primary concern. Intubation
does not carry the potential to cause suffocation.
3. The nurse is caring for a client with increased intracranial
pressure (ICP) caused by a traumatic brain injury. Which of the
following clinical manifestations would suggest that the client
may be experiencing increased brain compression causing brain
stem damage? A. Hyperthermia B. Tachycardia C. Hypertension
D. Bradypnea
,USE FIRST NEUROLOGIC TRAUMA MSII EXAMS
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ANS: A Rationale: Signs of increasing ICP include slowing of the
heart rate (bradycardia), increasing systolic BP, and widening
pulse pressure. As brain compression increases, respirations
become rapid, BP may decrease, and the pulse slows further. A
rapid rise in body temperature is regarded as unfavorable.
Hyperthermia increases the metabolic demands of the brain
and may indicate brain stem damage.
4. A client is brought to the ED by family after falling off the
roof. The care team suspects an epidural hematoma, prompting
the nurse to anticipate for which priority intervention? A.
Insertion of an intracranial monitoring device B. Treatment with
antihypertensives C. Making openings in the skull D.
Administration of anticoagulant therapy
ANS: C Rationale: An epidural hematoma is considered an
extreme emergency. Marked neurologic deficit or respiratory
arrest can occur within minutes. Treatment consists of making
an opening through the skull to decrease ICP emergently,
remove the clot, and control the bleeding. Antihypertensive
medications would not be a priority. Anticoagulant therapy
should not be prescribed for a client who has a cranial bleed.
, USE FIRST NEUROLOGIC TRAUMA MSII EXAMS
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Insertion of an intracranial monitoring device may be done
during surgery, but is not the immediate priority.
5. The staff educator is precepting a nurse new to the critical
care unit when a client with a T2 spinal cord injury is admitted.
The client is soon exhibiting manifestations of neurogenic
shock. In addition to monitoring the client closely, what would
be the nurse's most appropriate action? A. Prepare to transfuse
packed red blood cells. B. Prepare for interventions to increase
the client's BP. C. Place the client in the Trendelenburg position.
D. Prepare an ice bath to lower core body temperature.
ANS: B Rationale: Manifestations of neurogenic shock include
decreased BP and heart rate; interventions should support and
increase BP. Transfusion, Trendelenburg, and ice baths are not
indicated.
6. An ED nurse has just received a call from EMS that they are
transporting a 17-year-old client who has just sustained a spinal
cord injury (SCI). The nurse recognizes that the most common
cause of this type of injury is what event? A. Syncope (fainting)
B. Suicide attempts C. Workplace injuries D. Motor vehicle
accidents
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SUCCESS
1. A client is brought to the trauma center by ambulance after
sustaining a high cervical spinal cord injury 11/2 hours ago.
Endotracheal intubation has been deemed necessary and the
nurse is preparing to assist. What nursing diagnosis should the
nurse associate with this procedure? A. Risk for impaired skin
integrity B. Risk for injury C. Risk for autonomic dysreflexia D.
Risk for suffocation
ANS: B Rationale: If endotracheal intubation is necessary,
extreme care is taken to avoid flexing or extending the client's
neck, which can result in extension of a cervical injury.
Intubation does not directly cause autonomic dysreflexia and
the threat to skin integrity is not a primary concern. Intubation
does not carry the potential to cause suffocation.
3. The nurse is caring for a client with increased intracranial
pressure (ICP) caused by a traumatic brain injury. Which of the
following clinical manifestations would suggest that the client
may be experiencing increased brain compression causing brain
stem damage? A. Hyperthermia B. Tachycardia C. Hypertension
D. Bradypnea
,USE FIRST NEUROLOGIC TRAUMA MSII EXAMS
WITH 100% CORRECT VERIFIED ANSWERS LATEST
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SUCCESS
ANS: A Rationale: Signs of increasing ICP include slowing of the
heart rate (bradycardia), increasing systolic BP, and widening
pulse pressure. As brain compression increases, respirations
become rapid, BP may decrease, and the pulse slows further. A
rapid rise in body temperature is regarded as unfavorable.
Hyperthermia increases the metabolic demands of the brain
and may indicate brain stem damage.
4. A client is brought to the ED by family after falling off the
roof. The care team suspects an epidural hematoma, prompting
the nurse to anticipate for which priority intervention? A.
Insertion of an intracranial monitoring device B. Treatment with
antihypertensives C. Making openings in the skull D.
Administration of anticoagulant therapy
ANS: C Rationale: An epidural hematoma is considered an
extreme emergency. Marked neurologic deficit or respiratory
arrest can occur within minutes. Treatment consists of making
an opening through the skull to decrease ICP emergently,
remove the clot, and control the bleeding. Antihypertensive
medications would not be a priority. Anticoagulant therapy
should not be prescribed for a client who has a cranial bleed.
, USE FIRST NEUROLOGIC TRAUMA MSII EXAMS
WITH 100% CORRECT VERIFIED ANSWERS LATEST
DOWNLOADED 2025/2026 BEST RATED A+ FOR
SUCCESS
Insertion of an intracranial monitoring device may be done
during surgery, but is not the immediate priority.
5. The staff educator is precepting a nurse new to the critical
care unit when a client with a T2 spinal cord injury is admitted.
The client is soon exhibiting manifestations of neurogenic
shock. In addition to monitoring the client closely, what would
be the nurse's most appropriate action? A. Prepare to transfuse
packed red blood cells. B. Prepare for interventions to increase
the client's BP. C. Place the client in the Trendelenburg position.
D. Prepare an ice bath to lower core body temperature.
ANS: B Rationale: Manifestations of neurogenic shock include
decreased BP and heart rate; interventions should support and
increase BP. Transfusion, Trendelenburg, and ice baths are not
indicated.
6. An ED nurse has just received a call from EMS that they are
transporting a 17-year-old client who has just sustained a spinal
cord injury (SCI). The nurse recognizes that the most common
cause of this type of injury is what event? A. Syncope (fainting)
B. Suicide attempts C. Workplace injuries D. Motor vehicle
accidents
