NSG 4100 EXAMINATION | EXAM 4 | TEST BANK
| 200+ Verified Questions & Answers | Latest Updated
Version | 100% Pass Success Resource | Instant
Download PDF
TOPICS COVERED
Traumatic brain injury
Increased intracranial pressure (ICP)
Cerebral aneurysm
Brain tumors
Intracranial hemorrhage
Subarachnoid hemorrhage
Spinal cord injury
Botulism
Emerging infectious diseases
NCLEX Next Gen clinical judgment case studies
Comprehensive dosage calculations
SECTION 1: TRAUMATIC BRAIN INJURY
1. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. The
nurse should prioritize which intervention?
A) Administer analgesic medication
B) Prepare for endotracheal intubation
C) Position the patient in Trendelenburg position
D) Apply wrist restraints
Answer: B) Prepare for endotracheal intubation
2. Which finding in a patient with a traumatic brain injury indicates Cushing's
triad?
A) Hypotension, tachycardia, tachypnea
,B) Hypertension, bradycardia, irregular respirations
C) Hypotension, bradycardia, irregular respirations
D) Hypertension, tachycardia, tachypnea
Answer: B) Hypertension, bradycardia, irregular respirations
3. The nurse is assessing a patient with an epidural hematoma. Which finding is
characteristic of this type of injury?
A) Lucid interval followed by rapid deterioration
B) Gradual onset of confusion over several days
C) Permanent loss of consciousness from impact
D) Rapid improvement without intervention
Answer: A) Lucid interval followed by rapid deterioration
4. A patient with a traumatic brain injury has an intracranial pressure of 22 mmHg.
The nurse should:
A) Document this as a normal finding
B) Elevate the head of the bed to 30 degrees
C) Administer IV fluids at 200 mL/hr
D) Position the patient flat and supine
Answer: B) Elevate the head of the bed to 30 degrees
5. Which assessment finding in a patient with a traumatic brain injury indicates
worsening intracranial pressure?
A) Pupils equal and reactive bilaterally
B) Decorticate posturing
C) Glasgow Coma Scale score of 14
D) Blood pressure 120/80 mmHg
Answer: B) Decorticate posturing
6. The nurse is caring for a patient with a subdural hematoma. Which statement
about this condition is correct?
A) It is typically caused by arterial bleeding
B) It is more common in older adults due to brain atrophy
C) Symptoms develop rapidly within minutes
D) Surgical evacuation is never indicated
Answer: B) It is more common in older adults due to brain atrophy
7. A patient with a traumatic brain injury has a PaCO2 of 55 mmHg. The nurse
should anticipate which intervention?
A) Increase the ventilator rate to lower PaCO2
B) Decrease the ventilator rate to raise PaCO2
,C) Administer sodium bicarbonate
D) Administer oxygen via non-rebreather mask
Answer: A) Increase the ventilator rate to lower PaCO2
8. Which medication does the nurse anticipate administering to a patient with
increased intracranial pressure to reduce cerebral edema?
A) Furosemide
B) Mannitol
C) Spironolactone
D) Hydrochlorothiazide
Answer: B) Mannitol
9. A patient with a traumatic brain injury is exhibiting decerebrate posturing. The
nurse interprets this as:
A) Less severe than decorticate posturing
B) Indicative of damage to the brainstem
C) A normal response to pain
D) A voluntary protective mechanism
Answer: B) Indicative of damage to the brainstem
10. The nurse should monitor a patient with a traumatic brain injury for which
complication of hyperventilation therapy?
A) Increased intracranial pressure
B) Cerebral ischemia
C) Pulmonary edema
D) Hyponatremia
Answer: B) Cerebral ischemia
11. Which finding is most indicative of a basilar skull fracture?
A) Battle's sign
B) Unilateral pupil dilation
C) Hemiplegia
D) Seizure activity
Answer: A) Battle's sign
12. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 12.
The nurse should assess the patient for:
A) Need for immediate intubation
B) Deterioration in neurological status
C) Permanent brain damage
, D) Normal neurological functioning
Answer: B) Deterioration in neurological status
13. Which intervention should the nurse include in the plan of care for a patient
with a traumatic brain injury to minimize increased intracranial pressure?
A) Cluster all nursing activities together
B) Suction the patient frequently
C) Provide a calm, quiet environment
D) Keep the patient in a supine position
Answer: C) Provide a calm, quiet environment
14. A patient with a traumatic brain injury has a serum sodium of 155 mEq/L. The
nurse suspects which complication?
A) Syndrome of inappropriate antidiuretic hormone
B) Diabetes insipidus
C) Cerebral salt wasting
D) Hyperaldosteronism
Answer: B) Diabetes insipidus
15. The nurse is assessing a patient with a traumatic brain injury for signs of
increased intracranial pressure. Which finding is an early sign?
A) Cheyne-Stokes respirations
B) Fixed and dilated pupils
C) Headache and nausea
D) Decerebrate posturing
Answer: C) Headache and nausea
16. A patient with a traumatic brain injury is receiving phenytoin. The nurse
understands this medication is prescribed to:
A) Reduce cerebral edema
B) Prevent seizures
C) Decrease intracranial pressure
D) Improve cerebral perfusion
Answer: B) Prevent seizures
17. Which finding in a patient with a traumatic brain injury requires immediate
notification of the healthcare provider?
A) Glasgow Coma Scale score decreases from 13 to 10
B) Blood pressure increases from 130/80 to 140/85 mmHg
C) Temperature increases from 98.6°F to 99.2°F
| 200+ Verified Questions & Answers | Latest Updated
Version | 100% Pass Success Resource | Instant
Download PDF
TOPICS COVERED
Traumatic brain injury
Increased intracranial pressure (ICP)
Cerebral aneurysm
Brain tumors
Intracranial hemorrhage
Subarachnoid hemorrhage
Spinal cord injury
Botulism
Emerging infectious diseases
NCLEX Next Gen clinical judgment case studies
Comprehensive dosage calculations
SECTION 1: TRAUMATIC BRAIN INJURY
1. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 8. The
nurse should prioritize which intervention?
A) Administer analgesic medication
B) Prepare for endotracheal intubation
C) Position the patient in Trendelenburg position
D) Apply wrist restraints
Answer: B) Prepare for endotracheal intubation
2. Which finding in a patient with a traumatic brain injury indicates Cushing's
triad?
A) Hypotension, tachycardia, tachypnea
,B) Hypertension, bradycardia, irregular respirations
C) Hypotension, bradycardia, irregular respirations
D) Hypertension, tachycardia, tachypnea
Answer: B) Hypertension, bradycardia, irregular respirations
3. The nurse is assessing a patient with an epidural hematoma. Which finding is
characteristic of this type of injury?
A) Lucid interval followed by rapid deterioration
B) Gradual onset of confusion over several days
C) Permanent loss of consciousness from impact
D) Rapid improvement without intervention
Answer: A) Lucid interval followed by rapid deterioration
4. A patient with a traumatic brain injury has an intracranial pressure of 22 mmHg.
The nurse should:
A) Document this as a normal finding
B) Elevate the head of the bed to 30 degrees
C) Administer IV fluids at 200 mL/hr
D) Position the patient flat and supine
Answer: B) Elevate the head of the bed to 30 degrees
5. Which assessment finding in a patient with a traumatic brain injury indicates
worsening intracranial pressure?
A) Pupils equal and reactive bilaterally
B) Decorticate posturing
C) Glasgow Coma Scale score of 14
D) Blood pressure 120/80 mmHg
Answer: B) Decorticate posturing
6. The nurse is caring for a patient with a subdural hematoma. Which statement
about this condition is correct?
A) It is typically caused by arterial bleeding
B) It is more common in older adults due to brain atrophy
C) Symptoms develop rapidly within minutes
D) Surgical evacuation is never indicated
Answer: B) It is more common in older adults due to brain atrophy
7. A patient with a traumatic brain injury has a PaCO2 of 55 mmHg. The nurse
should anticipate which intervention?
A) Increase the ventilator rate to lower PaCO2
B) Decrease the ventilator rate to raise PaCO2
,C) Administer sodium bicarbonate
D) Administer oxygen via non-rebreather mask
Answer: A) Increase the ventilator rate to lower PaCO2
8. Which medication does the nurse anticipate administering to a patient with
increased intracranial pressure to reduce cerebral edema?
A) Furosemide
B) Mannitol
C) Spironolactone
D) Hydrochlorothiazide
Answer: B) Mannitol
9. A patient with a traumatic brain injury is exhibiting decerebrate posturing. The
nurse interprets this as:
A) Less severe than decorticate posturing
B) Indicative of damage to the brainstem
C) A normal response to pain
D) A voluntary protective mechanism
Answer: B) Indicative of damage to the brainstem
10. The nurse should monitor a patient with a traumatic brain injury for which
complication of hyperventilation therapy?
A) Increased intracranial pressure
B) Cerebral ischemia
C) Pulmonary edema
D) Hyponatremia
Answer: B) Cerebral ischemia
11. Which finding is most indicative of a basilar skull fracture?
A) Battle's sign
B) Unilateral pupil dilation
C) Hemiplegia
D) Seizure activity
Answer: A) Battle's sign
12. A patient with a traumatic brain injury has a Glasgow Coma Scale score of 12.
The nurse should assess the patient for:
A) Need for immediate intubation
B) Deterioration in neurological status
C) Permanent brain damage
, D) Normal neurological functioning
Answer: B) Deterioration in neurological status
13. Which intervention should the nurse include in the plan of care for a patient
with a traumatic brain injury to minimize increased intracranial pressure?
A) Cluster all nursing activities together
B) Suction the patient frequently
C) Provide a calm, quiet environment
D) Keep the patient in a supine position
Answer: C) Provide a calm, quiet environment
14. A patient with a traumatic brain injury has a serum sodium of 155 mEq/L. The
nurse suspects which complication?
A) Syndrome of inappropriate antidiuretic hormone
B) Diabetes insipidus
C) Cerebral salt wasting
D) Hyperaldosteronism
Answer: B) Diabetes insipidus
15. The nurse is assessing a patient with a traumatic brain injury for signs of
increased intracranial pressure. Which finding is an early sign?
A) Cheyne-Stokes respirations
B) Fixed and dilated pupils
C) Headache and nausea
D) Decerebrate posturing
Answer: C) Headache and nausea
16. A patient with a traumatic brain injury is receiving phenytoin. The nurse
understands this medication is prescribed to:
A) Reduce cerebral edema
B) Prevent seizures
C) Decrease intracranial pressure
D) Improve cerebral perfusion
Answer: B) Prevent seizures
17. Which finding in a patient with a traumatic brain injury requires immediate
notification of the healthcare provider?
A) Glasgow Coma Scale score decreases from 13 to 10
B) Blood pressure increases from 130/80 to 140/85 mmHg
C) Temperature increases from 98.6°F to 99.2°F
