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Question 1Neurological Assessment and Monitoring in the Critically Ill Child

A 6-year-old is admitted after a fall. Which finding on the Glasgow Coma Scale would score the lowest possible eye-opening component?

  1. No eye opening even to painful stimulation Correct answer.
  2. Spontaneous eye opening
  3. Eye opening to painful stimulation only
  4. Eye opening to a spoken command

Explanation

The eye-opening component of the Glasgow Coma Scale ranges from 4 (spontaneous) to 1 (no opening). The lowest score of 1 is assigned when the eyes do not open to any stimulus, including pain. Eye opening only to pain scores 2 and to voice scores 3.

Question 2Neurological Assessment and Monitoring in the Critically Ill Child

Which age-appropriate tool is designed specifically to assess level of consciousness in infants too young for the verbal Glasgow Coma Scale component?

  1. The APGAR score at 5 minutes
  2. The Pediatric Glasgow Coma Scale with infant adaptations Correct answer.
  3. The Faces Pain Scale
  4. The Adult Glasgow Coma Scale verbal score

Explanation

The Pediatric Glasgow Coma Scale modifies the verbal and motor descriptors so they fit infants and young children, such as crying, cooing, and age-appropriate motor responses. This preserves a comparable 3-to-15 total. Adult verbal descriptors and pain scales do not measure consciousness in infants.

Question 3Neurological Assessment and Monitoring in the Critically Ill Child

A nurse is preparing to measure intracranial pressure. At what anatomic landmark should the transducer be leveled to obtain accurate readings?

  1. The mid-abdomen
  2. The xiphoid process
  3. The tragus of the ear, approximating the level of the foramen of Monro Correct answer.
  4. The angle of Louis

Explanation

Intracranial pressure is referenced to the level of the foramen of Monro, which is approximated externally by the tragus of the ear or the outer canthus of the eye. Zeroing and leveling at this landmark ensures readings reflect true intracranial pressure. Other body landmarks produce falsely high or low values.

Question 4Neurological Assessment and Monitoring in the Critically Ill Child

Which set of findings best describes the Cushing triad seen with rising intracranial pressure?

  1. Hypotension, bradycardia, and apnea
  2. Hypotension, tachycardia, and tachypnea
  3. Hypertension, tachycardia, and hyperthermia
  4. Hypertension with widened pulse pressure, bradycardia, and irregular respirations Correct answer.

Explanation

Cushing triad consists of hypertension often with a widened pulse pressure, bradycardia, and irregular or depressed respirations. It reflects brainstem compression and is a late, ominous sign of raised intracranial pressure. Hypotension and tachycardia suggest shock rather than herniation.

Question 5Neurological Assessment and Monitoring in the Critically Ill Child

When assessing the pupillary response of a child with suspected raised intracranial pressure, which finding is most concerning for brainstem compression?

  1. Mild anisocoria present since birth
  2. A fixed, dilated pupil that does not react to light Correct answer.
  3. Brisk constriction to light in both eyes
  4. Equal pupils that constrict to accommodation

Explanation

A fixed, dilated pupil suggests compression of the oculomotor nerve, often from temporal lobe herniation. Loss of the light reflex indicates worsening brainstem function. Brisk, equal reactivity or long-standing benign anisocoria is not acutely alarming.

Question 6Neurological Assessment and Monitoring in the Critically Ill Child

Which finding on assessment of a critically ill child most suggests meningeal irritation?

  1. Flaccid tone in all limbs
  2. Neck stiffness with resistance to flexion Correct answer.
  3. Bilateral ankle clonus alone
  4. Pinpoint pupils bilaterally

Explanation

Nuchal rigidity, resistance to neck flexion, is a classic sign of meningeal irritation along with photophobia and headache. Flaccid tone, pinpoint pupils, and isolated clonus reflect other neurologic processes. Recognizing meningeal signs prompts urgent evaluation for infection or hemorrhage.

Question 7Neurological Assessment and Monitoring in the Critically Ill Child

A child with a ventriculoperitoneal shunt is admitted with lethargy and headache. Which assessment is most important for detecting shunt malfunction?

  1. Auscultation of bowel sounds
  2. Assessment of peripheral pulses
  3. Daily weights only
  4. Serial neurologic checks including level of consciousness and fontanelle status Correct answer.

Explanation

Shunt malfunction produces rising intracranial pressure, so serial neurologic assessment of consciousness, pupils, and, in infants, the fontanelle is essential. Bowel sounds, weights, and pulses do not reflect shunt function. Early detection prevents herniation.

Question 8Neurological Assessment and Monitoring in the Critically Ill Child

Which technique is correct when performing a painful stimulus to assess a child's motor response?

  1. Shake the child's shoulders vigorously
  2. Press firmly on a fingertip for several seconds
  3. Rub the sternum with an open palm repeatedly
  4. Apply a central stimulus such as trapezius squeeze or supraorbital pressure Correct answer.

Explanation

Central painful stimuli such as trapezius squeeze or supraorbital pressure are used to assess motor response because they are reliable and less likely to cause injury. Peripheral nail-bed pressure is discouraged because it may not reliably elicit a central response. Vigorous shaking risks harm and is not a standardized stimulus.

Question 9Neurological Assessment and Monitoring in the Critically Ill Child

An infant's anterior fontanelle is bulging and tense. What does this finding most likely indicate?

  1. Normal closure of the suture line
  2. Increased intracranial pressure Correct answer.
  3. Dehydration
  4. Hypoglycemia

Explanation

A bulging, tense anterior fontanelle in an infant suggests raised intracranial pressure because the open sutures allow outward bulging. A sunken fontanelle suggests dehydration. Fontanelle assessment is a key noninvasive indicator in infants whose skull can accommodate expanding volume.

Question 10Neurological Assessment and Monitoring in the Critically Ill Child

Which parameter on a bedside monitor most directly reflects cerebral perfusion pressure in a child with an intracranial pressure monitor?

  1. Systolic blood pressure minus heart rate
  2. Mean arterial pressure minus intracranial pressure Correct answer.
  3. Diastolic blood pressure plus intracranial pressure
  4. Intracranial pressure plus central venous pressure

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure. It estimates the pressure driving blood flow to the brain. Maintaining adequate cerebral perfusion pressure prevents secondary ischemic injury after brain insult.

Question 11Neurological Assessment and Monitoring in the Critically Ill Child

A child's Glasgow Coma Scale score drops from 12 to 8 over two hours. What is the most appropriate interpretation?

  1. An artifact that should be ignored until the next shift
  2. A normal fluctuation that requires no action
  3. An improvement indicating recovery
  4. A significant deterioration that warrants urgent escalation and airway assessment Correct answer.

Explanation

A decline of several points on the Glasgow Coma Scale signals worsening neurologic status and possible herniation. A score of 8 or below generally prompts evaluation of airway protection and urgent escalation. Trending scores over time is more valuable than a single measurement.

Question 12Neurological Assessment and Monitoring in the Critically Ill Child

During assessment of a sedated child, the nurse notes decerebrate posturing. What does this finding suggest?

  1. An intact cortex with mild dysfunction
  2. A purely peripheral nerve injury
  3. Brainstem or corticospinal tract injury with a poorer prognosis Correct answer.
  4. Normal flexor withdrawal from pain

Explanation

Decerebrate posturing, with extension and internal rotation of the limbs, indicates damage at or below the brainstem level and carries a worse prognosis than decorticate posturing. Decorticate posturing involves abnormal flexion and suggests injury above the brainstem. Recognizing the pattern guides urgency of intervention.

Question 13Neurological Assessment and Monitoring in the Critically Ill Child

Which nursing action best prevents artifacts and false readings during intracranial pressure monitoring?

  1. Flushing the system briskly every hour
  2. Disconnecting the monitor during repositioning without rezeroing
  3. Keeping the head of bed flat at all times
  4. Ensuring the transducer is zeroed and leveled at the tragus after position changes Correct answer.

Explanation

Intracranial pressure readings are affected by head position, so the transducer must be rezeroed and leveled at the tragus whenever the child's position changes. Brisk flushing and disconnection without rezeroing introduce artifact and risk. Accurate readings guide therapy for raised pressure.

Question 14Neurological Assessment and Monitoring in the Critically Ill Child

A child with suspected bacterial meningitis needs a lumbar puncture. Which assessment should be completed before the procedure?

  1. Testing of visual acuity
  2. Measurement of ankle-brachial index
  3. Assessment of bowel sounds
  4. Fundoscopic and neurologic evaluation for signs of raised intracranial pressure Correct answer.

Explanation

Lumbar puncture is deferred when signs of raised intracranial pressure or focal deficits are present because of the risk of herniation. A neurologic and fundoscopic examination screens for papilledema and focal signs. Blood cultures and antibiotics are often started before the procedure.

Question 15Neurological Assessment and Monitoring in the Critically Ill Child

Which finding in a child with a traumatic brain injury should prompt immediate concern for herniation syndrome?

  1. A single episode of hiccups
  2. A unilateral dilated pupil with decreasing consciousness Correct answer.
  3. Bilateral equal pupils with normal reactivity
  4. Complaint of mild thirst

Explanation

A unilateral dilated pupil combined with declining consciousness indicates uncal herniation from mass effect. This is a neurologic emergency requiring immediate escalation. Symmetric reactive pupils and minor symptoms are not herniation signs.

Question 16Neurological Assessment and Monitoring in the Critically Ill Child

A 3-year-old is being monitored with a ventricular drain. Which action is correct when the nurse needs to reposition the child?

  1. Raise the drain above the head to speed drainage
  2. Clamp the drain per protocol, reposition, then relevel and reopen as ordered Correct answer.
  3. Leave the drain open and unclamped during repositioning
  4. Flush the drain to check patency

Explanation

Ventricular drains must be managed per protocol during repositioning to prevent over- or under-drainage; clamping, repositioning, then releveling and reopening is standard. Leaving the drain open while moving can cause abrupt pressure changes. Flushing is not a routine nursing action and can introduce infection.

Question 17Neurological Assessment and Monitoring in the Critically Ill Child

Which assessment best evaluates brainstem function in an unresponsive child?

  1. Testing corneal, gag, and oculocephalic reflexes Correct answer.
  2. Auscultating lung sounds
  3. Measuring grip strength
  4. Checking capillary refill in the toes

Explanation

Brainstem reflexes such as corneal, gag, cough, and oculocephalic responses assess the function of cranial nerve pathways in the brainstem. Loss of these reflexes signals severe brainstem dysfunction. Grip strength, capillary refill, and lung sounds assess other systems.

Question 18Neurological Assessment and Monitoring in the Critically Ill Child

A child's pupils are pinpoint bilaterally after a suspected overdose. Which mechanism best explains this finding?

  1. Oculomotor nerve compression
  2. Sympathetic overactivity
  3. Pontine dysfunction or opioid effect on the pupillary pathway Correct answer.
  4. Early herniation of the temporal lobe

Explanation

Pinpoint pupils can result from pontine injury or opioid toxicity affecting the pupillary pathways. Oculomotor compression typically causes a dilated, fixed pupil. Sympathetic overactivity would dilate, not constrict, the pupils.

Question 19Neurological Assessment and Monitoring in the Critically Ill Child

Which monitoring approach is most useful for detecting early seizures in a sedated, paralyzed child?

  1. Continuous electroencephalographic monitoring Correct answer.
  2. Hourly temperature checks
  3. Daily weights
  4. Serial blood glucose measurements

Explanation

Sedation and neuromuscular blockade can mask the motor signs of seizures, so continuous EEG detects electrographic seizures that would otherwise be missed. Temperature, weights, and glucose do not detect seizure activity. Early detection allows timely treatment.

Question 20Neurological Assessment and Monitoring in the Critically Ill Child

A child has a Glasgow Coma Scale score of 6 and is not protecting the airway. Which intervention is the priority?

  1. Prepare for endotracheal intubation and airway support Correct answer.
  2. Encourage oral fluids
  3. Delay action and reassess in one hour
  4. Obtain a routine chest radiograph

Explanation

A Glasgow Coma Scale score of 8 or less with inability to protect the airway indicates the need for intubation and ventilatory support. Airway takes priority over diagnostic studies. Delaying intervention risks aspiration and hypoxia.

Question 21Neurological Assessment and Monitoring in the Critically Ill Child

Which statement best explains why infants may show fewer focal neurologic signs than older children after brain injury?

  1. Infants cannot mount an inflammatory response
  2. Infants have fully fused skulls that prevent swelling
  3. Infant brains lack pain receptors
  4. Open sutures and incomplete myelination can allow volume expansion and alter motor expression Correct answer.

Explanation

The open sutures and fontanelles allow the infant skull to expand somewhat, and incomplete myelination changes how motor deficits appear. This can delay recognition of focal signs. Clinicians therefore rely more on fontanelle, feeding, and behavioral changes.

Question 22Neurological Assessment and Monitoring in the Critically Ill Child

A child with hydrocephalus has a ventricular drain. The nurse notes the drainage has become dark and the pressure waveform has flattened. What is the most likely cause?

  1. Improved cerebral compliance
  2. Excessive sedation
  3. Blockage or displacement of the catheter Correct answer.
  4. Normal circadian variation

Explanation

Loss of the characteristic pulsatile waveform with altered drainage suggests catheter obstruction or displacement rather than normal function. Improved compliance would not flatten the waveform. The nurse should assess and notify the provider promptly.

Question 23Neurological Assessment and Monitoring in the Critically Ill Child

Which factor most increases the risk of secondary brain injury during transport of a child with raised intracranial pressure?

  1. Adequate sedation
  2. Maintaining normothermia
  3. Episodes of hypotension and hypoxemia Correct answer.
  4. Continuous pulse oximetry

Explanation

Hypotension and hypoxemia are major causes of secondary brain injury because they reduce oxygen delivery to an already vulnerable brain. Maintaining normothermia, oxygenation monitoring, and adequate sedation are protective. Preventing these insults during transport is a key priority.

Question 24Neurological Assessment and Monitoring in the Critically Ill Child

A child's intracranial pressure is 20 mm Hg and mean arterial pressure is 60 mm Hg. What is the cerebral perfusion pressure, and how should it be interpreted?

  1. 40 mm Hg, which is low and requires intervention Correct answer.
  2. 120 mm Hg, which is high
  3. 20 mm Hg, which is normal
  4. 80 mm Hg, which is normal

Explanation

Cerebral perfusion pressure is mean arterial pressure minus intracranial pressure, so 60 minus 20 equals 40 mm Hg. This is below the desired range and signals inadequate cerebral blood flow. The care team should act to improve perfusion.

Question 25Neurological Assessment and Monitoring in the Critically Ill Child

Which observation in a child with an external ventricular drain suggests possible over-drainage?

  1. Gradual improvement in consciousness
  2. Sudden headache and a collapsed ventricle with low drainage pressure Correct answer.
  3. Stable drain output at the prescribed rate
  4. Brisk pupillary responses

Explanation

Over-drainage can cause ventricular collapse, headache, and even subdural bleeding from excessive cerebrospinal fluid removal. It occurs when the drainage pressure is too low or the system is positioned improperly. The nurse should assess and notify the provider.

Question 26Neurological Assessment and Monitoring in the Critically Ill Child

Which component of the pediatric Glasgow Coma Scale assesses brainstem function most directly?

  1. Best motor response of the arms
  2. Spontaneous respiratory effort
  3. Eye opening response Correct answer.
  4. Best verbal response

Explanation

Eye opening is mediated by brainstem arousal pathways, so the eye-opening component reflects the integrity of the reticular activating system and brainstem more directly than cortical or spinal responses. Loss of eye opening with no response to pain indicates severe brainstem dysfunction.

Question 27Neurological Assessment and Monitoring in the Critically Ill Child

A nurse is preparing to assess a toddler's level of consciousness. Which approach is most appropriate to obtain a reliable examination?

  1. Observe the child at play before applying any stimulation Correct answer.
  2. Assess the child only while deeply asleep to avoid agitation
  3. Perform the most painful stimulus first to establish a baseline
  4. Ask the parents to leave the room to reduce distraction

Explanation

Observation during spontaneous activity gives the most valid picture of a young child's baseline responsiveness, because toddlers cannot cooperate with commands and may cry or withdraw from any handling. Stimulation should be graded from least to most intrusive only after spontaneous behavior is noted.

Question 28Neurological Assessment and Monitoring in the Critically Ill Child

Which finding is the earliest and most sensitive indicator of deteriorating neurologic status in a critically ill child?

  1. Loss of the gag reflex
  2. Fixed and dilated pupils
  3. Decerebrate posturing
  4. Change in level of consciousness Correct answer.

Explanation

A declining level of consciousness typically precedes brainstem signs because diffuse cortical or ascending reticular dysfunction occurs before herniation compresses brainstem structures. Pupillary changes, lost airway reflexes, and posturing are later and more ominous findings.

Question 29Neurological Assessment and Monitoring in the Critically Ill Child

A child with a severe traumatic brain injury has a mean arterial pressure of 65 mm Hg and an intracranial pressure of 18 mm Hg. What is the cerebral perfusion pressure?

  1. 83 mm Hg
  2. 47 mm Hg Correct answer.
  3. 53 mm Hg
  4. 18 mm Hg

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure, so 65 minus 18 gives 47 mm Hg. This value falls below the usual pediatric target range and signals a risk of cerebral ischemia that requires urgent intervention.

Question 30Neurological Assessment and Monitoring in the Critically Ill Child

A child with an external ventricular drain has a prescribed drainage height of 10 cm above the tragus. The child is repositioned from supine to a 30-degree head elevation. What action should the nurse take?

  1. Relevel the drain to remain 10 cm above the tragus in the new position Correct answer.
  2. Lower the drain to keep it at the previous vertical height above the bed
  3. Clamp the drain until the child returns to the supine position
  4. Raise the drain 10 cm higher to compensate for the change in posture

Explanation

The drainage chamber must be referenced to a fixed anatomic landmark, the tragus, so that the prescribed pressure gradient is maintained regardless of body position. After any repositioning, the nurse relevels the system to the tragus to prevent over-drainage or under-drainage.

Question 31Neurological Assessment and Monitoring in the Critically Ill Child

A child with meningitis has a heart rate of 180 beats per minute, blood pressure of 70/40 mm Hg, and capillary refill of 4 seconds. Which finding most strongly suggests that the neurologic changes are secondary to poor perfusion?

  1. Delayed capillary refill with widened pulse pressure Correct answer.
  2. A temperature of 38.5 degrees Celsius
  3. Nuchal rigidity on passive neck flexion
  4. Photophobia reported by the child

Explanation

Prolonged capillary refill with a widened pulse pressure indicates the vasodilated, high-cardiac-output phase of septic shock, which can impair cerebral perfusion and alter mental status. Recognizing shock as a cause of neurologic deterioration directs treatment toward fluid and vasoactive support rather than assuming primary brain injury.

Question 32Neurological Assessment and Monitoring in the Critically Ill Child

During intracranial pressure monitoring, a child's waveform shows a sudden loss of pulsatility with a flat tracing while the child remains stable. What is the most appropriate initial nursing action?

  1. Administer a prescribed osmotic diuretic
  2. Check the system for kinks, air, or disconnection at the transducer Correct answer.
  3. Document the finding and reassess in one hour
  4. Increase the head of bed to 45 degrees

Explanation

A flat or non-pulsatile waveform usually reflects a technical problem such as a kink, air bubble, clot, or loose connection rather than a true change in intracranial pressure. The nurse should first verify the system and patient, because treating an artifact as a real pressure reading can cause harm.

Question 33Neurological Assessment and Monitoring in the Critically Ill Child

A child with a known seizure disorder is sedated and receiving neuromuscular blockade. Which monitoring method is most appropriate for detecting subclinical seizure activity?

  1. Daily transcranial Doppler studies
  2. Hourly measurement of intracranial pressure
  3. Continuous electroencephalographic monitoring Correct answer.
  4. Serial pupillary examinations

Explanation

Neuromuscular blockade masks the motor manifestations of seizures, so only electroencephalography can reveal ongoing electrical seizure activity in a paralyzed child. Continuous monitoring allows detection and treatment of nonconvulsive status epilepticus that would otherwise go unnoticed.

Question 34Neurological Assessment and Monitoring in the Critically Ill Child

A 6-month-old with a ventricular shunt presents with a bulging fontanelle, sunsetting eyes, and increasing irritability. Which pathophysiologic process best explains these findings?

  1. Excessive cerebrospinal fluid absorption causing low ventricular pressure
  2. Demyelination of the corticospinal tracts
  3. Obstruction of cerebrospinal fluid flow causing rising ventricular pressure Correct answer.
  4. Loss of cerebral autoregulation causing systemic hypotension

Explanation

Shunt obstruction raises ventricular pressure, and the infant's open sutures and fontanelle transmit that pressure as a tense bulge. Downward pressure on the tectal region produces the sunsetting eye sign, and rising pressure causes irritability that progresses to lethargy.

Question 35Neurological Assessment and Monitoring in the Critically Ill Child

A child with an intracranial pressure monitor has a mean arterial pressure of 70 mm Hg and an intracranial pressure of 22 mm Hg. The child becomes more drowsy and the pupils are sluggish. Which interpretation is most accurate?

  1. The findings are consistent with a normal diurnal variation
  2. Cerebral perfusion pressure is adequate and observation is sufficient
  3. The pupils indicate a benign pharmacologic effect
  4. Cerebral perfusion pressure is inadequate and urgent intervention is needed Correct answer.

Explanation

Cerebral perfusion pressure here is 48 mm Hg, which is below the usual target for a child and is accompanied by clinical signs of worsening brain function. Combined with a declining level of consciousness and sluggish pupils, this pattern indicates impending herniation and requires immediate escalation of care.

Question 36Neurological Assessment and Monitoring in the Critically Ill Child

A child with a traumatic brain injury is being transported for computed tomography. Which action best protects cerebral oxygenation during the transfer?

  1. Hyperventilating the child continuously to a low carbon dioxide level
  2. Removing the intracranial pressure monitor to speed the transfer
  3. Keeping the head of bed flat to reduce the risk of falling
  4. Maintaining adequate sedation, ventilation, and blood pressure throughout the move Correct answer.

Explanation

Secondary injury during transport arises from hypoxia, hypotension, and uncontrolled intracranial pressure, so preserving oxygenation, ventilation, and perfusion is the priority. Continuous monitoring and adequate sedation reduce the risk of pressure surges and metabolic stress during the move.

Question 37Traumatic Brain Injury and Spinal Cord Injury

A child with severe traumatic brain injury is intubated. Which ventilation goal best prevents secondary brain injury from hyperventilation?

  1. Allow PaCO2 to rise above 50 mmHg
  2. Maintain normocapnia with PaCO2 near 35-40 mmHg Correct answer.
  3. Target PaCO2 below 20 mmHg for the first 24 hours
  4. Keep PaCO2 at 25-30 mmHg continuously

Explanation

Routine hyperventilation lowers PaCO2, causing cerebral vasoconstriction that can reduce cerebral blood flow and worsen ischemia. Guidelines therefore recommend maintaining normocapnia (about 35-40 mmHg) unless there is acute herniation. Brief hyperventilation may be used as a temporizing rescue measure only.

Question 38Traumatic Brain Injury and Spinal Cord Injury

Which finding is the earliest reliable sign of rising intracranial pressure in a child with a traumatic brain injury?

  1. Change in level of consciousness Correct answer.
  2. Cushing triad with bradycardia
  3. Fixed dilated pupils
  4. Decerebrate posturing

Explanation

A declining level of consciousness is typically the earliest and most sensitive indicator of worsening intracranial pressure. Pupillary changes, Cushing triad, and posturing are later signs that indicate more advanced herniation risk. Frequent neurologic checks are essential for early detection.

Question 39Traumatic Brain Injury and Spinal Cord Injury

A 6-year-old with a severe TBI has an intracranial pressure of 22 mmHg and a mean arterial pressure of 60 mmHg. What is the cerebral perfusion pressure?

  1. 22 mmHg
  2. 38 mmHg Correct answer.
  3. 82 mmHg
  4. 60 mmHg

Explanation

Cerebral perfusion pressure equals mean arterial pressure minus intracranial pressure (CPP = MAP - ICP). Here 60 minus 22 equals 38 mmHg. This value is below the usual pediatric target, so treatment to lower ICP or support blood pressure is needed.

Question 40Traumatic Brain Injury and Spinal Cord Injury

In a child with severe TBI, which head position is recommended to help control intracranial pressure?

  1. Prone position with head rotated
  2. Head of bed flat with head turned to the side
  3. Trendelenburg position with head lowered
  4. Head of bed elevated 30 degrees with head midline Correct answer.

Explanation

Elevating the head of the bed about 30 degrees with the head kept midline promotes venous drainage from the brain and can lower intracranial pressure. Head rotation or flat positioning impedes jugular venous return. The head should be kept aligned to avoid increasing intrathoracic pressure transmitted to the brain.

Question 41Traumatic Brain Injury and Spinal Cord Injury

Which intravenous fluid is preferred for initial resuscitation of a child with traumatic brain injury and hypotension?

  1. Free water boluses of 5% dextrose
  2. Hypertonic saline as the sole first-line fluid for all children
  3. Hypotonic saline (0.45% NaCl)
  4. Isotonic crystalloid such as 0.9% sodium chloride Correct answer.

Explanation

Isotonic crystalloid, typically 0.9% sodium chloride, is used for volume resuscitation because hypotonic fluids can worsen cerebral edema. Hypotonic solutions lower serum osmolality and promote fluid shift into brain tissue. Hypertonic saline is a therapy for intracranial hypertension, not routine initial resuscitation fluid.

Question 42Traumatic Brain Injury and Spinal Cord Injury

Which sign suggests a basilar skull fracture in a child after head trauma?

  1. Clear fluid leaking from the nose Correct answer.
  2. A single episode of vomiting
  3. A scalp hematoma over the occiput
  4. Bilateral periorbital bruising only

Explanation

Clear rhinorrhea after head trauma may represent cerebrospinal fluid leakage through a fracture of the anterior skull base. Testing for glucose or beta-2 transferrin can confirm CSF. This finding requires careful monitoring for meningitis risk.

Question 43Traumatic Brain Injury and Spinal Cord Injury

A child with a TBI has a Glasgow Coma Scale score of 7. What is the most appropriate airway management?

  1. Nasopharyngeal airway placement
  2. Observe with continuous pulse oximetry only
  3. Oral suctioning as needed without intubation
  4. Endotracheal intubation for airway protection Correct answer.

Explanation

A Glasgow Coma Scale score of 8 or less indicates severe brain injury with impaired airway reflexes, so endotracheal intubation is indicated to protect the airway and control ventilation. Intubation also allows controlled normocapnia. Nasopharyngeal airways are avoided when basilar skull fracture is possible.

Question 44Traumatic Brain Injury and Spinal Cord Injury

Which medication is used to reduce intracranial pressure through an osmotic effect in a child with acute TBI?

  1. Fosphenytoin
  2. Midazolam
  3. Ketamine
  4. Mannitol Correct answer.

Explanation

Mannitol is an osmotic diuretic that draws fluid from brain tissue and lowers intracranial pressure. It must be given through a filter and monitored for renal effects and osmolality. The other agents serve sedation, seizure prophylaxis, or analgesia rather than osmotic therapy.

Question 45Traumatic Brain Injury and Spinal Cord Injury

A child with severe TBI is being monitored. Which parameter is most important to maintain to prevent secondary brain injury?

  1. Serum glucose above 300 mg/dL
  2. Permissive hypoxemia
  3. Adequate oxygenation and blood pressure Correct answer.
  4. Core temperature above 39 degrees Celsius

Explanation

Secondary brain injury is driven by hypoxia, hypotension, hyperthermia, and hyperglycemia, so maintaining oxygenation and adequate perfusion pressure is central to neuroprotection. Avoiding hypoxia and hypotension has the strongest association with improved outcomes. Glucose and temperature should be kept in normal ranges.

Question 46Traumatic Brain Injury and Spinal Cord Injury

Which finding in a child after head trauma most suggests a cervical spine injury requiring immobilization?

  1. Midline neck tenderness with paresthesias Correct answer.
  2. A small abrasion on the forehead
  3. Bruising over the shin
  4. Complaint of mild headache

Explanation

Midline cervical tenderness combined with neurologic symptoms such as paresthesias raises strong suspicion for cervical spine injury. Spinal precautions should be maintained until imaging and clinical clearance. Isolated minor abrasions or extremity bruises do not suggest cervical injury.

Question 47Traumatic Brain Injury and Spinal Cord Injury

A child with a suspected unstable cervical spine injury needs airway management. Which approach is recommended?

  1. Apply traction to the head during laryngoscopy
  2. Remove the cervical collar and hyperextend the neck
  3. Place the child in the sniffing position without stabilization
  4. Perform manual in-line stabilization during intubation Correct answer.

Explanation

Manual in-line stabilization maintains cervical alignment while allowing airway management in a patient with suspected unstable spine injury. The collar may be opened anteriorly during intubation while an assistant stabilizes the head. Excessive extension or traction can worsen spinal cord injury.

Question 48Traumatic Brain Injury and Spinal Cord Injury

Which statement about spinal shock is accurate?

  1. It is a transient loss of reflexes and flaccidity below the injury Correct answer.
  2. It is defined as permanent spastic paralysis
  3. It resolves within minutes of injury
  4. It refers to hypotension from blood loss only

Explanation

Spinal shock is a temporary physiologic state after spinal cord injury marked by flaccid paralysis, loss of reflexes, and loss of sensation below the level of injury. It can last days to weeks and must be distinguished from neurogenic shock, which involves hemodynamic instability. Recovery of reflexes signals its resolution.

Question 49Traumatic Brain Injury and Spinal Cord Injury

A child with a high cervical spinal cord injury develops bradycardia and hypotension with warm dry skin. Which condition is most likely?

  1. Neurogenic shock Correct answer.
  2. Septic shock
  3. Hypovolemic shock from hemorrhage
  4. Anaphylactic shock

Explanation

Neurogenic shock results from loss of sympathetic tone after high cervical cord injury, producing bradycardia, hypotension, and warm dry extremities. It differs from hypovolemic shock, in which tachycardia and cool skin are typical. Treatment includes fluids, vasopressors, and sometimes atropine for bradycardia.

Question 50Traumatic Brain Injury and Spinal Cord Injury

Which intervention is appropriate for a child with acute spinal cord injury to reduce secondary cord damage?

  1. Routinely administer high-dose corticosteroids to all patients
  2. Maintain spinal immobilization and adequate perfusion Correct answer.
  3. Encourage early unprotected mobilization
  4. Apply aggressive hyperthermia

Explanation

Care after spinal cord injury focuses on immobilization to prevent further mechanical injury and on maintaining oxygenation and perfusion to limit secondary damage. High-dose steroids are not routinely recommended for pediatric spinal cord injury. Preventing hypotension and hypoxia is central to neuroprotection.