TRAUMA/SCI/TBI/ICP NCLEX EXAM
QUESTIONS AND ANSWERS (VERIFIED
AND UPDATED)
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 - ANS 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.
@2026/2027 ALLRIGHTS RESERVED.
,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 - ANS 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 - ANS 2.) B D A C E
Rationale:
@2026/2027 ALLRIGHTS RESERVED.
, 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. - ANS 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 - ANS 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.
@2026/2027 ALLRIGHTS RESERVED.
QUESTIONS AND ANSWERS (VERIFIED
AND UPDATED)
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 - ANS 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.
@2026/2027 ALLRIGHTS RESERVED.
,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 - ANS 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 - ANS 2.) B D A C E
Rationale:
@2026/2027 ALLRIGHTS RESERVED.
, 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. - ANS 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 - ANS 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.
@2026/2027 ALLRIGHTS RESERVED.
