Traumatic brain injury NCLEX questions
ACTUAL UPDATED QUESTIONS AND
CORRECT ANSWERS
Which of the following represents the best explanation of secondary brain injury?
A. Trauma to the brain causes bleeding and swelling of the tissues increasing pressure within
the brain
B. Trauma to neurons from the impact of the injury impairs brain function
C. Breathing problems and low blood pressure cause chemical changes that contribute to
brain swelling
D. Swelling of the axon of the nerve causes it to disconnect from the cell body interrupting
conduction of the impulse - CORRECT ANSWERS✅✅C. Breathing problems and low
blood pressure cause chemical changes that contribute to brain swelling
On arrival to the ED, which nursing assessment has highest priority for the client with likely
traumatic brain injury?
A. Testing for alcohol or drugs
B. Monitoring urine output
C. Assessing level of consciousness
D. Checking for pupil response to light - CORRECT ANSWERS✅✅C. Assessing level of
consciousness
The GCS score for your client with a risk for increased intracranial pressure has been stable
at 12 for the last 6 hours. This time you rate him at 9. Which of the following have you noted
and what does it mean?
A. He is less responsive, a sign that his intracranial pressure may be increasing
B. He is more responsive, a sign that he may be improving
C. His pupils are fixed and dilated, an ominous sign
, D. He does not move or make sounds, which may mean he got too much pain medication -
CORRECT ANSWERS✅✅A. He is less responsive, a sign that his intracranial pressure may
be increasing
The client is arousable only if his trapezius muscle is pinched. How will the nurse document
this client's level of consciousness?
A. Stuporous
B. Lethargic
C. Comatose
D. Drowsy - CORRECT ANSWERS✅✅A. Stuporous
A 17 year-old man is admitted to the Trauma Intensive Care Unit after sustaining a closed
head injury in a gang related fight. The nurse in the Emergency Department (ED) reported
that his VS before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS:
BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate
response to this assessment data?
A. Inform the attending physician of the change in assessment
B. Give the client intravenous naloxone (Narcan) as ordered
C. Call the laboratory and request a stat blood draw for drug screen
D. Lower the head of the client's bed flat immediately - CORRECT ANSWERS✅✅A.
Inform the attending physician of the change in assessment
The nurse is assessing the client with a traumatic brain injury after a skateboarding accident.
Which symptom is the nurse most concerned about?
A. Amnesia for events of accident
B. Bleeding head laceration
C. Pupil changes in one eye
D. Restlessness and confusion - CORRECT ANSWERS✅✅C. Pupil changes in one eye
ACTUAL UPDATED QUESTIONS AND
CORRECT ANSWERS
Which of the following represents the best explanation of secondary brain injury?
A. Trauma to the brain causes bleeding and swelling of the tissues increasing pressure within
the brain
B. Trauma to neurons from the impact of the injury impairs brain function
C. Breathing problems and low blood pressure cause chemical changes that contribute to
brain swelling
D. Swelling of the axon of the nerve causes it to disconnect from the cell body interrupting
conduction of the impulse - CORRECT ANSWERS✅✅C. Breathing problems and low
blood pressure cause chemical changes that contribute to brain swelling
On arrival to the ED, which nursing assessment has highest priority for the client with likely
traumatic brain injury?
A. Testing for alcohol or drugs
B. Monitoring urine output
C. Assessing level of consciousness
D. Checking for pupil response to light - CORRECT ANSWERS✅✅C. Assessing level of
consciousness
The GCS score for your client with a risk for increased intracranial pressure has been stable
at 12 for the last 6 hours. This time you rate him at 9. Which of the following have you noted
and what does it mean?
A. He is less responsive, a sign that his intracranial pressure may be increasing
B. He is more responsive, a sign that he may be improving
C. His pupils are fixed and dilated, an ominous sign
, D. He does not move or make sounds, which may mean he got too much pain medication -
CORRECT ANSWERS✅✅A. He is less responsive, a sign that his intracranial pressure may
be increasing
The client is arousable only if his trapezius muscle is pinched. How will the nurse document
this client's level of consciousness?
A. Stuporous
B. Lethargic
C. Comatose
D. Drowsy - CORRECT ANSWERS✅✅A. Stuporous
A 17 year-old man is admitted to the Trauma Intensive Care Unit after sustaining a closed
head injury in a gang related fight. The nurse in the Emergency Department (ED) reported
that his VS before transfer were: BP 136/70, HR 92, RR 22. Your assessment indicates VS:
BP 168/54, HR 50, RR 10 and irregular. Which of the following is the most appropriate
response to this assessment data?
A. Inform the attending physician of the change in assessment
B. Give the client intravenous naloxone (Narcan) as ordered
C. Call the laboratory and request a stat blood draw for drug screen
D. Lower the head of the client's bed flat immediately - CORRECT ANSWERS✅✅A.
Inform the attending physician of the change in assessment
The nurse is assessing the client with a traumatic brain injury after a skateboarding accident.
Which symptom is the nurse most concerned about?
A. Amnesia for events of accident
B. Bleeding head laceration
C. Pupil changes in one eye
D. Restlessness and confusion - CORRECT ANSWERS✅✅C. Pupil changes in one eye
