‼️FINAL HEAD INJURY‼️

Question 1

What is the earliest and most reliable indicator of a head injury leading to increased ICP?
A. Blood pressure
B. Level of consciousness
C. Heart rate
D. Respiratory rate

Answer 1

Answer: B. Level of consciousness
Rationale: A change in LOC is the earliest sign of increased ICP due to impaired cerebral blood flow.

Question 2

Which of the following is a hallmark sign of a basilar skull fracture?
A. Periorbital edema
B. Raccoon eyes
C. Tinnitus
D. Unequal pupils

Answer 2

Answer: B. Raccoon eyes
Rationale: Raccoon eyes (periorbital bruising) suggest basilar skull fracture with potential dural tear.

Question 3

What is the first nursing action when CSF otorrhea is noted?
A. Irrigate the ear
B. Apply pressure to the ear
C. Notify the healthcare provider
D. Insert a cotton swab

Answer 3

Answer: C. Notify the healthcare provider
Rationale: CSF leakage indicates a possible skull fracture and risk of infection—needs immediate attention.

Question 4

What Glasgow Coma Scale score indicates a severe head injury?
A. 13–15
B. 9–12
C. 3–8
D. 16–20

Answer 4

Answer: C. 3–8
Rationale: A score of 3–8 reflects severe brain injury and requires urgent intervention.

Question 5

What does Battle sign indicate?
A. Epidural hematoma
B. Frontal skull fracture
C. Basilar skull fracture
D. Orbital fracture

Answer 5

Answer: C. Basilar skull fracture
Rationale: Battle sign (bruising behind the ears) is commonly associated with fractures at the base of the skull.

Question 6

Which symptom is associated with a concussion?
A. Loss of long-term memory
B. Seizure
C. Retrograde amnesia
D. Hyperthermia

Answer 6

Answer: C. Retrograde amnesia
Rationale: Concussions can cause brief memory loss before the injury (retrograde amnesia).

Question 7

What clinical finding is associated with diffuse axonal injury (DAI)?
A. Unequal pupils
B. Decerebrate posturing
C. Raccoon eyes
D. Clear CSF rhinorrhea

Answer 7

Answer: B. Decerebrate posturing
Rationale: DAI can lead to deep unconsciousness and abnormal brainstem posturing.

Question 8

Why is mannitol given to patients with increased ICP?
A. Treat infection
B. Increase blood pressure
C. Decrease cerebral edema
D. Reduce seizure activity

Answer 8

Answer: C. Decrease cerebral edema
Rationale: Mannitol draws fluid out of brain tissue, reducing ICP.

Question 9

What is a hallmark symptom of an epidural hematoma?
A. Slow onset of symptoms
B. Lucid interval followed by unconsciousness
C. Drowsiness and confusion
D. Chronic symptoms

Answer 9

Answer: B. Lucid interval followed by unconsciousness
Rationale: A classic epidural hematoma pattern is brief consciousness, then rapid deterioration.

Question 10

At what ICP level is immediate treatment required?
A. >10 mmHg
B. >15 mmHg
C. >20 mmHg
D. >25 mmHg

Answer 10

Answer: C. >20 mmHg
Rationale: Sustained ICP above 20 mmHg is considered dangerously elevated.

Question 11

What is a complication of a skull fracture with CSF rhinorrhea?
A. Seizure
B. Cerebral edema
C. Meningitis
D. Hemorrhage

Answer 11

Answer: C. Meningitis
Rationale: CSF leaks provide a route for pathogens, increasing meningitis risk.

Question 12

Which intervention helps prevent herniation in a head trauma patient?
A. Trendelenburg position
B. Elevating HOB to 30 degrees
C. Turning side-to-side rapidly
D. Administering glucose

Answer 12

Answer: B. Elevating HOB to 30 degrees
Rationale: This promotes venous return and helps reduce ICP.

Question 13

What assessment finding suggests worsening ICP after head injury?
A. Dilated pupils
B. Increased temperature
C. Lethargy
D. All of the above

Answer 13

Answer: D. All of the above
Rationale: These are signs of increased ICP and potential brainstem compromise.

Question 14

Which head injury is most likely to rebleed or enlarge over time?
A. Epidural hematoma
B. Contusion
C. DAI
D. Skull fracture

Answer 14

Answer: B. Contusion
Rationale: Brain contusions can “blossom” and expand on imaging over hours to days.

Question 15

Which cranial nerve is affected in uncal herniation?
A. CN II
B. CN III
C. CN V
D. CN VIII

Answer 15

Answer: B. CN III
Rationale: CN III controls pupil response—compression causes dilated, unresponsive pupils.

Question 16

What is a sign of acute subdural hematoma?
A. Gradual change in LOC
B. Lucid interval
C. Immediate unconsciousness
D. Focal seizure

Answer 16

Answer: C. Immediate unconsciousness
Rationale: Acute subdural hematomas typically present with decreased LOC right after injury.

Question 17

What is the best diagnostic tool for acute head trauma?
A. MRI
B. PET scan
C. CT scan
D. X-ray

Answer 17

Answer: C. CT scan
Rationale: A CT scan provides rapid and accurate assessment for bleeding and fractures.

Question 18

What is the most dangerous potential complication of a head injury?
A. Hemiplegia
B. Brain herniation
C. Memory loss
D. Seizures

Answer 18

Answer: B. Brain herniation
Rationale: Herniation compresses vital brain structures and can be fatal.

Question 19

Which position should be avoided in head injury patients?
A. Supine
B. Prone
C. Trendelenburg
D. Semi-Fowler’s

Answer 19

Answer: C. Trendelenburg
Rationale: This increases ICP and should be avoided.

Question 20

What pupil change is concerning in a head injury patient?
A. Equal and reactive
B. Sluggish but reactive
C. Unilateral fixed dilation
D. Bilateral pinpoint

Answer 20

Answer: C. Unilateral fixed dilation
Rationale: Indicates potential herniation and pressure on cranial nerve III.

Question 20

What are signs of postconcussion syndrome?
A. Seizure, nausea
B. Persistent headache, mood changes
C. Visual hallucinations
D. Tachypnea and dizziness

Answer 20

Answer: B. Persistent headache, mood changes
Rationale: Long-term symptoms may include behavioral and cognitive disturbances.

Question 21

What is a late sign of increasing ICP?
A. Headache
B. Irritability
C. Cushing’s triad
D. Lethargy

Answer 21

Answer: C. Cushing’s triad
Rationale: Bradycardia, hypertension, and irregular respirations occur with severe ICP elevation.

Question 22

What is the most appropriate IV fluid for head injury?
A. D5W
B. 0.45% NS
C. 0.9% NS
D. LR with glucose

Answer 22

Answer: C. 0.9% NS
Rationale: Isotonic saline prevents cerebral edema unlike hypotonic solutions.

Question 23

Which type of hematoma often occurs in older adults after minor trauma?
A. Epidural
B. Acute subdural
C. Chronic subdural
D. Intracerebral

Answer 23

Answer: C. Chronic subdural
Rationale: Brain atrophy increases subdural space, predisposing older adults to slow bleeds.

Question 24

What does CSF look like on a gauze test when mixed with blood? A. Pink B. Bright red C. Halo sign D. Foamy

Answer 24

Answer: C. Halo sign Rationale: Blood pools in the center with a yellowish ring; suggesting CSF.

Question 25

What is a priority nursing diagnosis for head trauma? A. Risk for infection B. Risk for ineffective cerebral perfusion C. Disturbed body image D. Risk for falls

Answer 25

Answer: B. Risk for ineffective cerebral perfusion Rationale: Maintaining adequate cerebral blood flow is the top priority.

Question 26

What symptom may occur with frontal lobe contusion? A. Visual disturbance B. Aphasia C. Personality changes D. Seizures

Answer 26

Answer: C. Personality changes Rationale: Frontal lobe damage affects behavior, emotions, and decision-making.

Question 27

What is the cause of most epidural hematomas? A. Venous bleed B. Arterial tear C. Skull fracture D. Brain swelling

Answer 27

Answer: B. Arterial tear Rationale: Epidural bleeds usually involve the middle meningeal artery under the skull.

Question 28

What posturing indicates deeper brain injury than decorticate? A. Flexion posturing B. Decerebrate posturing C. Withdrawal D. Babinski sign

Answer 28

Answer: B. Decerebrate posturing Rationale: This posture indicates midbrain or brainstem dysfunction and worse prognosis.

Question 29

What is the best initial action for a head-injured patient with a GCS score of 6? A. Observe overnight B. Intubate and assess airway C. Recheck GCS in 2 hours D. Start seizure medications

Answer 29

Answer: B. Intubate and assess airway Rationale: GCS <8 suggests poor airway protection; intubation is necessary.

Question 30

Which information should the nurse include in teaching? "Concussion symptoms..." A. Should resolve within 24 hours B. Are always associated with seizure activity C. May last up to several weeks in some cases D. Always require hospitalization

Answer 30

Correct Answer: C. May last up to several weeks in some cases

Question 31

A nurse is assessing a client who sustained a closed head injury in a motor vehicle accident. The nurse notes bruising behind the client's left ear. Which of the following actions is the nurse’s priority? A. Document the findings and continue to monitor B. Elevate the head of the bed to 30 degrees C. Notify the healthcare provider immediately D. Apply ice to the bruised area to reduce swelling

Answer 31

Correct Answer: C. Notify the healthcare provider immediately Rationale: Bruising behind the ear (Battle sign) is indicative of a basilar skull fracture, which may involve a tear in the dura and increase the risk for CSF leakage, meningitis, and intracranial complications.