Nursing NUR408 Exam 4 – EAQs (Enhanced Assessment Questions) Evidence-Based Practice
Questions and Answers Study Guide
Which statement is accurate for management of a patient with traumatic brain injury (TBI)?
a. An adequate cough reflex will protect the patient's airway
b. Poor oral hygiene can lead to respiratory crisis from secretions
c. A tracheotomy is needed and will interfere with the patient's ability to communicate
d. The patient may not realistically expect to regain normal speech with vocal cord damage -
✔✔b. Poor oral hygiene can lead to respiratory crisis from secretions
Which phrase describes an open traumatic brain injury (TBI)?
a. An injury in which the skull is fractured
b. An injury in which the skull remains intact
c. An injury that damages only the brain tissue
d. An injury in which there is increased intracranial pressure (ICP) - ✔✔a. An injury in which
the skull is fractured
The nurse suspects which diagnosis when a patient's assessment findings include a recent blow
to the head with a heavy object, amnesia about the event, no loss of consciousness, and an MRI
that shows no evidence of brain damage?
a. Mild traumatic brain injury (MTBI)
b. Acute traumatic brain injury
c. Severe traumatic brain injury
d. Moderate traumatic brain injury - ✔✔a. Mild traumatic brain injury (MTBI)
Rationale: With moderate TBI, patients have loss of consciousness, and CT and MRI scans
usually show brain injury. Acute TBI is not a real category. And with severe TBI, the patient has
loss of consciousness, and CT and MRI scans catch tissue damage in the brain early.
,An impairment of which function could be the result of TBI? SATA.
a. mobility
b. cognition
c. reproduction
d. sensory perception
e. psychosocial function - ✔✔a. mobility
b. cognition
d. sensory perception
e. psychosocial function
Which causes of TBI in the U.S. are the most common? SATA.
a. falls
b. violence
c. physical abuse
d. sports-related injuries
e. motor vehicle crashes - ✔✔a. falls
e. motor vehicle crashes
Which symptom concerns the nurse the most when assessing a patient with a TBI after a
skateboarding incident?
a. amnesia
b. restlessness
c. head laceration
d. asymmetric pupils - ✔✔d. asymmetric pupils
Rationale: asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral pupils are
a sign of severe TBI. Amnesia, restless, and a head laceration could be symptoms of mild TBI.
,Which statement describes an indirect traumatic brain injury (TBI)?
a. Force was applied directly to the patient's head
b. Force was applied to the head by an object or tool, not another body part
c. Force was applied to another body part, but the brain was still affected
d. Force was applied to the brain because of an accident and not an intentional injury - ✔✔c.
Force was applied to another body part, but the brain was still affected
A patient who is scheduled to undergo bone marrow transplant will have high-dose
chemotherapy followed by total body irradiation (TBI) just before the transplant. Which
statement by the patient indicates a need for further teaching about the purpose of this
therapy?
a. my bone marrow cells will be obliterated
b. any remaining leukemic cells will be obliterated
c. graft-versus-host disease will control the cancer
d. my immune system will be replaced with the transplant - ✔✔c. graft-versus-host disease will
control the cancer
Rationale: Patients who are receiving lower (not higher) doses of chemotherapy and TBI rely on
graft-versus-host disease to control the cancer.
Which type of traumatic brain injury (TBI) is caused by an external force contacting the head,
suddenly placing the head in motion?
a. deceleration injury
b. acceleration injury
c. open traumatic brain injury
d. closed traumatic brain injury - ✔✔b. acceleration injury
Rationale: A deceleration injury occurs when the moving head is suddenly stopped or hits a
stationary object.
Which phrase describes TBI?
, a. injury to the brain from a congenital condition
b. damage to the brain from an external mechanical force
c. impairment of the brain caused by neurodegeneration
d. diminishing functionality of the brain due to internal forces - ✔✔b. damage to the brain
from an external mechanical force
Rationale: TBI is not caused by congenital conditions, neurodegeneration, or internal forces.
The nurse discusses which common cause of TBI in older adults when providing education for a
community group?
a. alzheimer disease
b. motor vehicle crashes
c. falls
d. stroke - ✔✔c. falls
Rationale: Alzheimer disease and strokes are not classified as TBIs.
To treat a patient with a severe TBI, which intervention reduces brain metabolism and prevents
the cascade of molecular and biochemical events that contribute to secondary brain injury?
a. a barbiturate coma
b. placement of an intraventricular catheter
c. therapeutic hypothermia
d. a decompressive craniectomy surgery - ✔✔c. therapeutic hypothermia
Since admission to the hospital after a TBI, a patient has been active and oriented and
experiencing mild headaches. Which action does the nurse take when increased dilation of the
pupils and a sluggish response to light are new assessment findings?
a. notify the health care provider immediately
b. reassess the patient in 2 hours
c. elevate the head of the bed to 60 degrees
Questions and Answers Study Guide
Which statement is accurate for management of a patient with traumatic brain injury (TBI)?
a. An adequate cough reflex will protect the patient's airway
b. Poor oral hygiene can lead to respiratory crisis from secretions
c. A tracheotomy is needed and will interfere with the patient's ability to communicate
d. The patient may not realistically expect to regain normal speech with vocal cord damage -
✔✔b. Poor oral hygiene can lead to respiratory crisis from secretions
Which phrase describes an open traumatic brain injury (TBI)?
a. An injury in which the skull is fractured
b. An injury in which the skull remains intact
c. An injury that damages only the brain tissue
d. An injury in which there is increased intracranial pressure (ICP) - ✔✔a. An injury in which
the skull is fractured
The nurse suspects which diagnosis when a patient's assessment findings include a recent blow
to the head with a heavy object, amnesia about the event, no loss of consciousness, and an MRI
that shows no evidence of brain damage?
a. Mild traumatic brain injury (MTBI)
b. Acute traumatic brain injury
c. Severe traumatic brain injury
d. Moderate traumatic brain injury - ✔✔a. Mild traumatic brain injury (MTBI)
Rationale: With moderate TBI, patients have loss of consciousness, and CT and MRI scans
usually show brain injury. Acute TBI is not a real category. And with severe TBI, the patient has
loss of consciousness, and CT and MRI scans catch tissue damage in the brain early.
,An impairment of which function could be the result of TBI? SATA.
a. mobility
b. cognition
c. reproduction
d. sensory perception
e. psychosocial function - ✔✔a. mobility
b. cognition
d. sensory perception
e. psychosocial function
Which causes of TBI in the U.S. are the most common? SATA.
a. falls
b. violence
c. physical abuse
d. sports-related injuries
e. motor vehicle crashes - ✔✔a. falls
e. motor vehicle crashes
Which symptom concerns the nurse the most when assessing a patient with a TBI after a
skateboarding incident?
a. amnesia
b. restlessness
c. head laceration
d. asymmetric pupils - ✔✔d. asymmetric pupils
Rationale: asymmetric (uneven) pupils, loss of light reaction, or unilateral or bilateral pupils are
a sign of severe TBI. Amnesia, restless, and a head laceration could be symptoms of mild TBI.
,Which statement describes an indirect traumatic brain injury (TBI)?
a. Force was applied directly to the patient's head
b. Force was applied to the head by an object or tool, not another body part
c. Force was applied to another body part, but the brain was still affected
d. Force was applied to the brain because of an accident and not an intentional injury - ✔✔c.
Force was applied to another body part, but the brain was still affected
A patient who is scheduled to undergo bone marrow transplant will have high-dose
chemotherapy followed by total body irradiation (TBI) just before the transplant. Which
statement by the patient indicates a need for further teaching about the purpose of this
therapy?
a. my bone marrow cells will be obliterated
b. any remaining leukemic cells will be obliterated
c. graft-versus-host disease will control the cancer
d. my immune system will be replaced with the transplant - ✔✔c. graft-versus-host disease will
control the cancer
Rationale: Patients who are receiving lower (not higher) doses of chemotherapy and TBI rely on
graft-versus-host disease to control the cancer.
Which type of traumatic brain injury (TBI) is caused by an external force contacting the head,
suddenly placing the head in motion?
a. deceleration injury
b. acceleration injury
c. open traumatic brain injury
d. closed traumatic brain injury - ✔✔b. acceleration injury
Rationale: A deceleration injury occurs when the moving head is suddenly stopped or hits a
stationary object.
Which phrase describes TBI?
, a. injury to the brain from a congenital condition
b. damage to the brain from an external mechanical force
c. impairment of the brain caused by neurodegeneration
d. diminishing functionality of the brain due to internal forces - ✔✔b. damage to the brain
from an external mechanical force
Rationale: TBI is not caused by congenital conditions, neurodegeneration, or internal forces.
The nurse discusses which common cause of TBI in older adults when providing education for a
community group?
a. alzheimer disease
b. motor vehicle crashes
c. falls
d. stroke - ✔✔c. falls
Rationale: Alzheimer disease and strokes are not classified as TBIs.
To treat a patient with a severe TBI, which intervention reduces brain metabolism and prevents
the cascade of molecular and biochemical events that contribute to secondary brain injury?
a. a barbiturate coma
b. placement of an intraventricular catheter
c. therapeutic hypothermia
d. a decompressive craniectomy surgery - ✔✔c. therapeutic hypothermia
Since admission to the hospital after a TBI, a patient has been active and oriented and
experiencing mild headaches. Which action does the nurse take when increased dilation of the
pupils and a sluggish response to light are new assessment findings?
a. notify the health care provider immediately
b. reassess the patient in 2 hours
c. elevate the head of the bed to 60 degrees
