Trauma/SCI/TBI/ICP NCLEX UPDATED ACTUAL Exam Questions and CORRECT Answers
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Course
Trauma/SCI/TBI/ICP NCLEX
Institution
Trauma/SCI/TBI/ICP NCLEX
Trauma/SCI/TBI/ICP NCLEX UPDATED
ACTUAL Exam Questions and
CORRECT Answers
You are working in the triage area of an ED, and four patients approach the triage desk at the
same time. List the order in which you will assess these patients:
a. An ambulatory, dazed 25-year-old male with a bandage...
Trauma/SCI/TBI/ICP NCLEX UPDATED
ACTUAL Exam Questions and
CORRECT Answers
You are working in the triage area of an ED, and four patients approach the triage desk at the
same time. List the order in which you will assess these patients:
a. An ambulatory, dazed 25-year-old male with a bandaged head wound
b. An irritable infant with a fever, petechiae, and nuchal rigidity
c. A 35-year-old jogger with a twisted ankle, having pedal pulse and no deformity
d. A 50-year-old female with moderate abdominal pain and occasional vomiting.
1.) A B D C
2.) B A D C
3.) C D B A
4.) C B A D - CORRECT ANSWER- ✔✔2.) B A D C
Rationale:
An irritable infant with fever and petechiae should be further assessed for other meningeal
signs. The patient with the head wound needs additional history and assessment for
intracranial pressure. The patient with moderate abdominal pain is uncomfortable, but not
unstable at this point. For the ankle injury, medical evaluation can be delayed 24 - 48 hours if
necessary.
In conducting a primary survey on a trauma patient, which of the following is considered one
of the priority elements of the primary survey?
a.) Complete set of vital signs
b.) Palpation and auscultation of the abdomen
c.) Brief neurologic assessment
d.) Initiation of pulse oximetry - CORRECT ANSWER- ✔✔c.) Brief neurologic assessment
,Rationale:
A brief neurologic assessment to determine level of consciousness and pupil reaction is part
of the primary survey. Vital signs, assessment of the abdomen, and initiation of pulse
oximetry are considered part of the secondary survey.
You respond to a call for help from the ED waiting room. There is an elderly patient lying on
the floor. List the order for the actions that you must perform.
a. Perform the chin lift or jaw thrust maneuver.
b. Establish unresponsiveness.
c. Initiate cardiopulmonary resuscitation (CPR).
d. Call for help and activate the code team.
e. Instruct a nursing assistant to get the crash cart.
1.) A B C E D
2.) B D A C E
3.) C A B E D
4.) D C B E A
5.) E C D B A - CORRECT ANSWER- ✔✔2.) B D A C E
Rationale:
Establish unresponsiveness first. (The patient may have fallen and sustained a minor injury.)
If the patient is unresponsive, get help and have someone initiate the code. Performing the
chin lift or jaw thrust maneuver opens the airway. The nurse is then responsible for starting
CPR. CPR should not be interrupted until the patient recovers or it is determined that heroic
efforts have been exhausted. A crash cart should be at the site when the code team arrives;
however, basic CPR can be effectively performed until the team arrives.
A client with trauma to the chest develops a tension pneumothorax. After a needle
thorocostomy is performed the nurse would expect:
a.) an increase in blood pressure.
b.) a decrease in blood pressure.
, c.) an increase in jugular venous distension.
d.) a decrease in level of consciousness. - CORRECT ANSWER- ✔✔a.) an increase in blood
pressure.
Rationale:
Clients presenting with tension pneumothorax would exhibit hypotension, jugular venous
distension, and decreasing level of consciousness. An increase in blood pressure should result
after a thoracostomy is performed.
A pediatric client is admitted to the neuro ICU with a closed-head injury sustained after
falling out of a tree house. The mechanisms of injury this young client most likely sustained
would be:
a.) Acceleration
b.) Penetrating
c.) Rotational
d.) Deceleration - CORRECT ANSWER- ✔✔d.) Deceleration
Rationale:
Deceleration injury occurs when the brain stops rapidly in the cranial vault. As the skull
ceases movement, the brain continues to move until it hits the skull. The force of deceleration
causes injury at the site of impact. An example of this is a victim of a fall.
A client who has had a plaster of Paris cast applied to his forearm is receiving pain
medication. To detect early manifestations of compartment syndrome, which of these
assessments should the nurse make?
A.) Observe the color of the fingers
B.) Palpate the radial pulse under the cast
C.) Check the cast for odor and drainage
D.) Evaluate the response to analgesics - CORRECT ANSWER- ✔✔D.) Evaluate the
response to analgesics
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