A 21-year-old male was admitted to the emergency department following a high-speed motorcycle accident.
He was reported to be unconscious at the scene, but upon arrival he was awake and oriented with a Glasgow Coma Scale (GCS) of 15. Suddenly, he becomes unconscious and mental status deteriorates to a GCS of 8. The nurse anticipates which of the following injuries?

Subarachnoid hemorrhage.

Diffuse axonal injury.

Epidural hematoma.

Subdural hematoma.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.

Choice B rationale

Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.

Choice C rationale

Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.

Choice D rationale

Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .

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Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

Correct Answer is ["56"]

Explanation

Step 1 is (250 mL ÷ 90 min) × 20 gtt/mL.

Step 2 is (2.777 mL/min × 20 gtt/mL).

Step 3 is 55.55 gtts/min. The final calculated answer is 56 gtts/min.

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Correct Answer is D

Explanation

A client is to receive 250 mL of IV fluid over 90 minutes by gravity. The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

Correct Answer is ["56"]

Explanation

A client has a past medical history of coronary artery disease and emphysema.The nurse knows which agent is safest to give?

A nurse is caring for a patient with a spinal cord injury who is about to be transferred to a wheelchair for physical therapy.The patient complains of feeling dizzy and is diaphoretic.What would be the priority nursing action?

The nurse is caring for several patients in the Intensive Care Unit (ICU). Which of the following patients is at the greatest risk of anoxic brain injury?

To decrease intraocular pressure following cataract surgery, the nurse should instruct the client to avoid:

A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?