Trauma Nursing: Head and Spinal Cord Injury Practice Questions
18 free Trauma Nursing: Head and Spinal Cord Injury practice questions for the NCLEX Exam. Tap an option to answer — you get instant feedback, the correct answer, and a detailed explanation for every question.
What is the first nursing action for a patient who fell from a height and is unconscious with a suspected cervical spine injury?
- A Remove the cervical collar and test neck range of motion
- B Maintain inline cervical immobilisation and assess airway, breathing, circulation
- C Sit the patient fully upright to better evaluate the neck pain
- D Have the patient turn the head side to side to check function
Correct answer: Maintain inline cervical immobilisation and assess airway, breathing, circulation
Suspected cervical spine injury mandates spinal immobilisation and ABC assessment to prevent secondary cord injury.
What does a Glasgow Coma Scale (GCS) score of 7 indicate in a head-injured patient?
- A Mild brain injury needing only minimal observation
- B Moderate brain injury that poses no immediate danger
- C Severe brain injury with high deterioration risk, may need airway protection
- D No brain injury, consistent with a fully normal exam
Correct answer: Severe brain injury with high deterioration risk, may need airway protection
GCS ≤ 8 typically denotes severe traumatic brain injury and warrants immediate management and possibly airway protection.
What does the triad of bradycardia, hypertension, and irregular respirations indicate in a head-injured patient?
- A A normal compensatory response to the head injury
- B The early onset of neurogenic shock from cord injury
- C Cushing's triad indicating raised intracranial pressure and herniation risk
- D The early stage of spinal shock after the trauma
Correct answer: Cushing's triad indicating raised intracranial pressure and herniation risk
The triad is hallmark for increased ICP and possible brain herniation.
What respiratory change can be anticipated in a patient with a spinal cord injury at level C4?
- A An unaffected diaphragm with fully normal breathing
- B Diaphragmatic paralysis likely requiring ventilatory support
- C Only a mild weakness of the cough effort
- D A spontaneous rise in resting tidal volume
Correct answer: Diaphragmatic paralysis likely requiring ventilatory support
Injury at C4 or above may impair the phrenic nerve innervation of the diaphragm, reducing breathing ability and often requiring mechanical ventilation.
What presentation characterizes neurogenic shock in the acute phase of spinal cord injury?
- A Hypertension with tachycardia and cool extremities
- B Hypotension, bradycardia, and warm dry skin from lost sympathetic tone
- C Narrow pulse pressure with marked tachypnoea
- D High systemic vascular resistance with a rapid heart rate
Correct answer: Hypotension, bradycardia, and warm dry skin from lost sympathetic tone
Loss of sympathetic innervation in high SCI causes vasodilation, bradycardia and hypotension (neurogenic shock).
Why is monitoring intracranial pressure (ICP) recommended for head-injured patients?
- A The patient is fully conscious with a GCS of 15 and normal CT
- B GCS below 9 with CT abnormalities such as swelling or midline shift
- C The patient is fully conscious with no neurologic deficit
- D The patient has only an isolated, uncomplicated limb fracture
Correct answer: GCS below 9 with CT abnormalities such as swelling or midline shift
ICP monitoring is indicated in patients with severe TBI (GCS ≤ 8 or 9) and CT evidence of swelling/herniation to guide management.
Why is elevating the head of the bed to 20-30° recommended for head-injured patients?
- A It promotes venous drainage from the brain and helps reduce ICP
- B It increases intracranial pressure by obstructing venous outflow
- C It is contraindicated until spine is cleared
- D It has no effect on brain perfusion
Correct answer: It promotes venous drainage from the brain and helps reduce ICP
Elevating head of bed helps venous drainage and reduces intracranial pressure; it's standard unless contraindicated by spine instability.
Which nursing intervention is essential for a patient with high-level spinal cord injury to prevent respiratory complications?
- A Encourage deep breathing exercises just once per shift
- B Pulmonary hygiene (suction, deep breathing, cough assist) plus vital capacity monitoring
- C Maintain immobilisation only and disregard lung function
- D Defer respiratory monitoring until the rehabilitation phase
Correct answer: Pulmonary hygiene (suction, deep breathing, cough assist) plus vital capacity monitoring
High SCI can impair respiratory muscles; nurses must monitor lung function, suction secretions, assist coughing to prevent pneumonia.
What target range should the nurse set the ventilator to maintain PaCO₂ for a head-injured patient with a GCS of 6?
- A 25 mmHg
- B 35-40 mmHg
- C 50 mmHg
- D 60 mmHg
Correct answer: 35-40 mmHg
Maintaining PaCO₂ around 35-40 mmHg helps preserve cerebral perfusion.
What does sudden onset headache, flushed skin above the injury level, and elevated blood pressure indicate in a patient with a spinal cord injury?
- A Spinal shock with flaccid paralysis
- B Autonomic dysreflexia from a noxious stimulus
- C Neurogenic shock with vasodilation
- D A normal compensatory cardiovascular response
Correct answer: Autonomic dysreflexia from a noxious stimulus
Autonomic dysreflexia occurs in SCI above T6; triggers (e.g., bladder distension) cause hypertension, headache, flushing above level.
Why is the 'log-roll' technique used when repositioning a patient with an acute cervical spine injury?
- A It lets the limbs be moved independently for greater speed
- B It moves the head, neck and spine as one unit, keeping alignment
- C It can be performed safely by a single person without help
- D It is only required once 48 hours have passed since injury
Correct answer: It moves the head, neck and spine as one unit, keeping alignment
Log-rolling ensures neutral spine movement and prevents further cord damage during repositioning in acute SCI.
What does clear fluid leaking from the nose after head trauma suggest in a patient?
- A Simple watery nasal secretion of no concern
- B Possible cerebrospinal fluid leak needing neurosurgical review
- C Ordinary allergic rhinorrhoea from the environment
- D Saliva tracking up from an associated oral injury
Correct answer: Possible cerebrospinal fluid leak needing neurosurgical review
Clear watery drainage with head trauma suggests CSF leak from skull base fracture; risk of meningitis and need for neurosurgical input.
What type of shock is likely causing symptoms of low blood pressure, bradycardia, and warm flushed skin in a patient with high thoracic spine trauma?
- A Hypovolemic shock
- B Neurogenic shock
- C Obstructive shock
- D Cardiogenic shock
Correct answer: Neurogenic shock
In high thoracic or cervical SCI, loss of sympathetic tone can cause vasodilation, bradycardia and hypotension characteristic of neurogenic shock.
What is a key nursing priority in the acute management of traumatic brain injury to prevent secondary brain injury?
- A Hypoxia and hypotension
- B Hyperoxygenation
- C Early mobilisation
- D Pain control
Correct answer: Hypoxia and hypotension
Hypoxia and hypotension worsen brain injury and increase mortality in TBI; stabilising airway, oxygenation and BP is essential.
Why is frequent assessment of skin integrity vital for patients with acute spinal cord injury?
- A Only superficial bruising from positioning
- B Pressure ulcers from immobility and loss of sensation
- C Only infectious wound complications occur
- D No meaningful skin problems are expected
Correct answer: Pressure ulcers from immobility and loss of sensation
SCI patients often lose sensation/immobility below injury level, increasing risk of pressure ulcers; proactive skin care is essential.
What assessment finding should be prioritised by the nurse as a sign of neurologic deterioration in head injury?
- A Pupils equal and reactive with an unchanged GCS
- B New decerebrate posturing with a unilateral fixed dilated pupil
- C A slight headache with no change on neuro exam
- D A small, transient increase in the heart rate
Correct answer: New decerebrate posturing with a unilateral fixed dilated pupil
Decerebrate posturing and unilateral dilated pupil indicate brain herniation or severe pathology and demand immediate action.
What preventive measures should the nurse take for a patient with spinal cord injury to reduce the risk of deep-vein thrombosis (DVT)?
- A No special measures are needed for this patient
- B Passive range of motion, compression devices, and ordered anticoagulants
- C Allow ambulation only once the patient feels ready
- D Wait until DVT symptoms develop and then begin treatment
Correct answer: Passive range of motion, compression devices, and ordered anticoagulants
Immobility and impaired circulation in SCI increase DVT risk; prophylaxis with ROM, devices and anticoagulants is required.
What action should the nurse take if the plateau pressures in a patient on mechanical ventilation for acute TBI are rising above 30 cm H₂O?
- A No action is needed as this is within the safe range
- B Notify the provider to adjust ventilation strategy to limit lung injury
- C Document the value and reassess at the next scheduled check
- D Increase the tidal volume to lower the airway pressure
Correct answer: Notify the provider to adjust ventilation strategy to limit lung injury
Plateau pressures above ~30 cm H2O reflect reduced lung compliance and raise the risk of ventilator-associated lung injury, which can worsen outcomes in acute TBI. The nurse should notify the provider so the ventilation strategy can be adjusted.