A client is admitted to the emergency department after a motor vehicle accident. The nurse notes that the client has a Glasgow Coma Scale (GCS) score of 7, is unresponsive to verbal commands, and has decerebrate posturing. The nurse would classify this head injury as:

Mild traumatic brain injury (TBI).

Moderate traumatic brain injury (TBI).

Severe traumatic brain injury (TBI).

Concussion.

Answer and Explanation

The Correct Answer is C

A Glasgow Coma Scale (GCS) score of 8 or below indicates a severe traumatic brain injury. A score of 9–12 is classified as moderate, while a score of 13–15 is mild. In this case, the client has a GCS of 7, is unresponsive to verbal stimuli, and exhibits decerebrate posturing, which are all consistent with a severe TBI.

Rationale for correct answer:
3. Severe traumatic brain injury (TBI). A GCS score ≤8 reflects severe neurologic impairment and often requires immediate airway and intracranial pressure management. Decerebrate posturing further supports significant brainstem dysfunction, which is life-threatening.

Rationale for incorrect answers:
1. Mild traumatic brain injury (TBI). Mild TBI corresponds to a GCS score of 13–15. Clients are usually alert or have only transient confusion, not posturing or unresponsiveness.
2. Moderate traumatic brain injury (TBI). Moderate TBI corresponds to a GCS score of 9–12. This client’s GCS of 7 is lower and falls in the severe range.
4. Concussion. A concussion is a type of mild TBI with temporary changes in mental status, often without structural brain injury. The client’s GCS and posturing rule out concussion.

Take-home points:

GCS is used to classify severity of brain injury: 13–15 = mild, 9–12 = moderate, ≤8 = severe.
A GCS of 7 indicates severe brain injury requiring aggressive monitoring and intervention.
Decerebrate posturing signifies serious brainstem damage and poor prognosis.
Early recognition of severity guides airway management, ICP monitoring, and neurosurgical interventions.

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Correct Answer is C

Explanation

A cerebral contusion is a bruise of the brain tissue resulting from blunt trauma, which can cause capillary bleeding, edema, and structural brain damage. This makes it more serious than a concussion, which is typically a temporary disruption in neurologic function without visible structural injury.

Rationale for correct answer:
3. Cerebral contusion. A contusion is an actual injury to the brain parenchyma, leading to localized bleeding, edema, and risk of secondary complications such as increased intracranial pressure.

Rationale for incorrect answers:
1. Is a temporary injury with no permanent damage. This describes a concussion, which usually results in transient neurologic dysfunction, not a contusion.
2. Is a type of closed head injury, while a concussion is an open head injury. Both concussions and contusions are forms of closed head injury; an open injury involves a skull fracture or penetrating wound.
4. Only affects the outer layer of the brain and does not cause a change in consciousness. A contusion can affect deeper brain structures and often does cause altered consciousness, depending on severity and location.

Take-home points:

Concussion = temporary neurologic dysfunction, no visible brain lesion.
Contusion = visible bruise/bleed on brain tissue, more serious.
Contusions can cause edema, increased ICP, seizures, or permanent damage.
Always monitor clients with contusions closely for signs of deterioration.

A. Depressed skull fracture. B. Linear skull fracture. C. Basilar skull fracture. D. Compound skull fracture.

Correct Answer is C

Explanation

Clear fluid drainage from the nose (possible cerebrospinal fluid leak) and raccoon eyes (periorbital ecchymosis) are classic signs of a basilar skull fracture, which involves the base of the skull. These findings indicate a potential dural tear and increased risk for meningitis due to CSF leakage.

Rationale for correct answer:
3. Basilar skull fracture. Basilar skull fractures commonly present with CSF rhinorrhea or otorrhea, raccoon eyes, or Battle’s sign (bruising behind the ears). These findings are hallmark indicators of this type of fracture.

Rationale for incorrect answers:
1. Depressed skull fracture. Involves bone fragments pressing inward, often seen with localized injury or lacerations, not typically with raccoon eyes or CSF leakage.
2. Linear skull fracture. A simple break in the bone without displacement. It usually does not produce obvious external signs like raccoon eyes or CSF drainage.
4. Compound skull fracture. Involves a break in the skin and skull bone exposure, increasing infection risk, but is not classically associated with raccoon eyes or CSF rhinorrhea.

Take-home points:

Basilar skull fracture = raccoon eyes, Battle’s sign, CSF leakage.
Always test drainage for CSF (halo sign or glucose testing) to confirm.
High infection risk → monitor closely for meningitis.
Avoid nasogastric tube insertion in suspected basilar fractures to prevent intracranial placement.

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A client is admitted to the emergency department after a motor vehicle accident. The nurse notes that the client has a Glasgow Coma Scale (GCS) score of 7, is unresponsive to verbal commands, and has decerebrate posturing. The nurse would classify this head injury as:

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Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with a head injury. The client's family asks the nurse about the difference between a concussion and a cerebral contusion. The nurse explains that a key distinction is that a cerebral contusion:

Correct Answer is C

Explanation

A patient with a head injury has clear fluid draining from their nose and bruises around their eyes (raccoon eyes). The nurse recognizes these findings as a classic sign of which type of skull fracture?

Correct Answer is C

Explanation

A patient comes to the emergency department with a history of a head injury and a brief period of unconsciousness followed by a lucid interval and then a rapid decline in level of consciousness. The nurse suspects the client has which type of hematoma?

A nurse is differentiating between a subdural hematoma and an epidural hematoma. Which of the following statements correctly describes a key difference between the two? (Select all that apply.)

A client is admitted to the emergency department after a motor vehicle accident. The nurse notes that the client has a Glasgow Coma Scale (GCS) score of 7, is unresponsive to verbal commands, and has decerebrate posturing. The nurse would classify this head injury as: