Question: Which assessment finding indicates a life-threatening intracranial pressure (ICP) elevation and likely brainstem herniation in a patient following a traumatic brain injury?
Answer Options:
Dilated, non-reactive pupils, Hyperventilation, Narrowed pulse pressure, Hypotension
Answer: Dilated, non-reactive pupils
Question: Which of the following assessment findings is most concerning for worsening prognosis?
Answer Options:
Temp 100.2°F, BP 132/80, HR 58, GCS score decreases by 2 points
Answer: GCS score decreases by 2 points
Question: Using the GCS scale provided, how would the RN evaluate Kara’s brain injury severity?
Answer Options:
Minor Brain Injury, Moderate Brain Injury, Severe Brain Injury
Answer: Moderate Brain Injury
Question: A patient with an ischemic stroke is being considered for tissue plasminogen activator (tPA). The nurse recognizes which factors as contraindications to this treatment?
Answer Options:
History of a stroke in the last month and received tPA then, Age 83 years, Symptoms present for 150 minutes, Takes warfarin for atrial fibrillation, CT scan demonstrates ischemic stroke
Answer: History of a stroke in the last month and received tPA then, Takes warfarin for atrial fibrillation
Question: A patient received alteplase for the treatment of ischemic stroke. Following drug administration, the nurse monitors for which adverse effect?
Answer Options:
Hypotension secondary to anaphylaxis, Elevated hematocrit or hemoglobin, Respiratory depression and low O2 saturation, Severe headache and hypertension
Answer: Severe headache and hypertension
Question: Which intervention is the priority in the nursing care of a patient with an epidural hematoma?
Answer Options:
Patient education on injury prevention, Administering fibrinolytic therapy within 2 hours of arrival to the ER, Frequent neurological assessments, Elevating the HOB to 30 degrees
Answer: Frequent neurological assessments
Question: The nurse is assessing a patient who was brought to the emergency department with speech impairment and weakness on one side of the body. Which clinical finding could help the nurse differentiate a transient ischemic attack (TIA) from a brain attack (stroke).
Answer Options:
Patient has unilateral body weakness, Symptoms resolve within 30 minutes, Patient has dysarthria, Patient has diabetes mellitus
Answer: Symptoms resolve within 30 minutes
Question: The RN is assessing a patient with increased intracranial pressure experiencing Cushing’s Triad. Which assessment findings does the nurse anticipate?
Answer Options:
Severe hypertension, Hypotension, Widened pulse pressure, Tachycardia, Bradycardia
Answer: Severe hypertension, Widened pulse pressure, Bradycardia
Question: Which determination must be made first in assessing a patient with traumatic brain injury?
Answer Options:
Glasgow Coma Scale, Presence of spinal injury, Patency of airway, Hypovolemia with hypotension
Answer: Patency of airway
Question: Which information indicates the patient may be experiencing central (brainstem) herniation? Select all that apply
Answer Options:
Non-reactive pupils, Ptosis, Cheyne-Stokes respirations, Reactive pupils
Answer: Non-reactive pupils, Ptosis, Cheyne-Stokes respirations
Question: Kara’s college coach inquires about possible post-concussion syndrome. The emergency room RN knows which symptoms are common with post-concussion syndrome?
Answer Options:
Dysarthria and expressive aphasia, Headache and light sensitivity, Amnesia and tinnitus, Inappropriate humor and mania
Answer: Headache and light sensitivity
Question: Which assessment finding are consistent with a mild traumatic brain injury: Select all that apply
Answer Options:
Dysarthria, Ataxia, Loss of consciousness for 20 minutes, Headache, Hemianopsia, Confusion
Answer: Loss of consciousness for 20 minutes, Headache, Confusion