Changed : New exam content outline; passing score · BCEN
Head and neck trauma, brain to orbit
TCRN · Clinical practice · 31 of 150 scored items
About one TCRN item in five comes from this domain. Expect a patient with a brain or cord injury whose numbers are drifting, or a face, neck or eye injury where the next nursing action matters more than the diagnosis.
BCEN names two groups (content outline); the subtopics are ours:
Traumatic brain injury: GCS and pupil checks, epidural, subdural and diffuse axonal injury, herniation, ICP and cerebral perfusion pressure.
Secondary brain injury: preventing hypoxia and hypotension and managing CO2, temperature, glucose and sodium.
Spinal cord injury: level and completeness, incomplete cord syndromes, neurogenic versus spinal shock, autonomic dysreflexia, breathing after a high injury.
Maxillofacial: midface and mandible fractures, orbital floor injury, CSF leak.
A parent asks why a child can have a spinal cord injury even though spine radiographs are normal. The nurse explains that the MAIN anatomic reason is:
Answer and why, all 4 options
The pediatric canal is relatively roomy; narrowing explains cord injury in older adults with spondylosis, not in children.
Children's spinal ligaments are lax, their facet joints are shallow and horizontal, and their heads are large for the body, so the column can stretch and spring back without a fracture. The cord, which tolerates far less stretch, can be injured even when radiographs look normal.
Young children have a high center of gravity because of their large heads, which concentrates force at the upper cervical spine.
Brittle bone would fracture and show on films; children's vertebrae are flexible, which is why bony injury may be absent.
Item 535676
Clinical Practice: Head and Neck · 31 items
When the nurse applies supraorbital pressure, the patient's right hand reaches to the stimulus, while the left arm flexes abnormally. The nurse scores the GCS motor response as:
Answer and why, all 4 options
A 6 requires obeying commands; responding to pain, however purposeful, does not reach that level.
A score of 4 is normal flexion withdrawal from pain; reaching to the stimulus is a higher-level, purposeful response.
The GCS motor score uses the best response from any limb. A hand that reaches toward the stimulus is localizing, which scores 5 even though the other arm flexes abnormally.
Abnormal flexion scores 3, but it is the worse side; scoring the poorer limb underestimates the patient.
Item 535707
Clinical Practice: Head and Neck · 31 items
A patient with an acute C5 spinal cord injury has serial bedside respiratory measurements. Which negative inspiratory force (NIF) value MOST strongly indicates the need for intubation?
Answer and why, all 4 options
A NIF of −45 is strong; reading the larger number as worse confuses the negative sign.
Negative inspiratory force reflects diaphragm strength, which weakens as a C3–C5 injury ascends or swells. Values weaker than about −20 cm H₂O signal impending ventilatory failure, so −15 is the most ominous and calls for early elective intubation.
A NIF of −60 is near normal for an adult and indicates good diaphragm function.
A NIF of −30 shows adequate inspiratory strength; it is still trended, but it does not by itself mandate intubation.
Item 535716
Clinical Practice: Head and Neck · 31 items
Two days after a basilar skull fracture with clear rhinorrhea, a patient has a temperature of 102.2°F (39°C), neck stiffness, and photophobia. The nurse should suspect
Answer and why, all 4 options
Headache is common after head injury, but it does not bring high fever and meningismus.
A basilar skull fracture with a CSF leak opens a path from the sinuses or ear to the subarachnoid space, so fever, neck stiffness, and photophobia days later suggest bacterial meningitis. Cultures and antibiotics follow promptly.
Vasospasm peaks days after a large subarachnoid hemorrhage and causes new deficits or confusion, but not fever with neck stiffness in a patient with a CSF leak.
An expanding hematoma causes declining consciousness and focal signs, not fever and photophobia.
Item 535873
Clinical Practice: Head and Neck · 31 items
A patient with a C6 spinal cord injury has no motor function below the injury but can feel light touch and pinprick around the anus. The nurse documents the ASIA Impairment Scale grade as:
Answer and why, all 4 options
Grade D requires that at least half of key muscles below the level have antigravity strength; the patient has no motor function.
Grade A means no sensory or motor function in the sacral segments; perianal sensation rules it out.
Preserved sensation at S4–S5 with no motor function below the level is AIS grade B. Sacral sparing defines an incomplete injury and carries a better outlook than grade A.
Grade C requires some motor function below the level, which this patient lacks.
Item 535883
Clinical Practice: Head and Neck · 31 items
After a high-speed crash, a patient has an elongated, flattened face, bilateral periorbital ecchymosis, and clear rhinorrhea. The entire midface, including the cheekbones, moves when the maxilla is grasped. These findings are consistent with
Answer and why, all 4 options
A Le Fort III fracture separates the entire midface, including the zygomas, from the skull base, so the whole face moves with the maxilla. A flattened, elongated face, raccoon eyes, and CSF rhinorrhea are typical, and airway compromise is a major risk.
A Le Fort I fracture is a horizontal break above the teeth; only the upper dental arch and palate move.
An arch fracture causes a depression in front of the ear and trismus, not mobility of the entire midface.
A Le Fort II is pyramidal through the nasal bridge and medial orbits; the zygomas stay fixed, so the cheekbones do not move with the maxilla.
Item 536035
Clinical Practice: Head and Neck · 31 items
A 6-year-old fell from standing onto a carpeted floor. The child has a GCS of 15, no loss of consciousness, no vomiting, normal behavior, and no scalp hematoma. The nurse should anticipate
Answer and why, all 4 options
Skull films miss intracranial injury and are not part of pediatric head injury decision rules.
Scanning a very low-risk child adds radiation exposure, which matters more in children, without a meaningful chance of finding an injury that needs treatment.
Admission is unnecessary for a child with no risk features; a period of ED observation and home teaching is enough.
A child over 2 with a normal GCS and mental status, no loss of consciousness, no vomiting, no signs of skull fracture, and a low-energy fall from standing is very low risk by PECARN. The child is observed and discharged with teaching, avoiding radiation.
Item 536037
Clinical Practice: Head and Neck · 31 items
A 5-year-old restrained passenger in a low-speed crash is alert and playing, with no neck pain or tenderness and a normal neurologic examination. The nurse understands that spinal motion restriction
Answer and why, all 4 options
Backboards are for extrication; even when restriction is needed, a collar and a flat stretcher are preferred.
Age alone is not an indication; routine immobilization of young children adds distress and unnecessary imaging.
CT is not needed in a low-risk child; clearance can be clinical, sparing radiation.
Spinal motion restriction is guided by clinical criteria such as altered mental status, neck pain or tenderness, focal deficits, and high-risk mechanisms. An alert child with a normal exam and no tenderness after a low-speed crash can be cleared without immobilization or imaging.
Item 536040
Clinical Practice: Head and Neck · 31 items
A patient with a suspected orbital floor fracture has double vision. To assess for extraocular muscle entrapment, the nurse should ask the patient to
Answer and why, all 4 options
A penlight tests pupillary response, not extraocular muscle movement.
Visual acuity is an important baseline, but it does not test eye movement or entrapment.
Tracking a target through the six cardinal gazes tests each extraocular muscle; with an orbital floor fracture, inability to look up and double vision on upgaze suggest inferior rectus entrapment, which can need early surgery.
Eyelid closure tests the facial nerve; it does not show whether an eye muscle is trapped.
Item 536048
Clinical Practice: Head and Neck · 31 items
A patient with CSF otorrhea from a basilar skull fracture is managed nonoperatively. Which instruction should the nurse give the patient?
Answer and why, all 4 options
Packing traps CSF and can create a path for infection; drainage is allowed to flow onto a loose sterile dressing.
Nose blowing and straining raise pressure across the fracture and can push bacteria and air into the cranial vault. Most leaks close on their own within days with the head elevated and these precautions.
The head is kept elevated to lower CSF pressure; lying flat increases the leak.
Inserting swabs into a leaking ear can carry organisms along the leak; only the outer ear is wiped.
Item 536097
Clinical Practice: Head and Neck · 31 items
Eight months after a T6 spinal cord injury, a patient reports new burning pain in the arms and loss of sensation that is rising above the original level. The nurse should suspect
Answer and why, all 4 options
Months to years after a cord injury, a fluid-filled cavity can form and extend upward, causing new burning pain and sensory loss that rises above the original level, often in the arms. MRI confirms it, and it needs neurosurgical evaluation.
A sacral wound is below the level and does not cause new arm pain or ascending sensory loss.
Dysreflexia causes sudden hypertension, headache, and flushing in response to a trigger, not progressive sensory loss.
Phantom sensations occur below the level and do not involve new loss of function above it; an ascending level is a new problem.
Item 536103
Clinical Practice: Head and Neck · 31 items
A patient has a small, expanding epidural hematoma, but intracranial pressure initially remains normal. The nurse understands this early compensation occurs because
Answer and why, all 4 options
Brain tissue is nearly incompressible; compressing it causes injury and herniation.
Adult sutures are fused; only infants with open fontanelles can expand the skull.
By the Monro-Kellie doctrine, the skull's volume is fixed, so an early mass is offset by moving CSF into the spinal subarachnoid space and squeezing venous blood out. Once these reserves are used up, small additions raise ICP sharply.
More arterial blood would add volume and raise ICP; compensation removes venous blood instead.
Item 536113
Clinical Practice: Head and Neck · 31 items
A patient struck on the temple has a GCS of 15 and no focal deficits. CT shows a 40-mL temporal epidural hematoma with 4 mm of midline shift. The nurse should anticipate
Answer and why, all 4 options
An epidural hematoma larger than 30 mL is evacuated regardless of the GCS, because these bleeds can expand quickly and cause sudden deterioration after a lucid interval.
Observation fits a small epidural hematoma (under 30 mL, thin, little shift, GCS above 8); a 40-mL hematoma has passed that threshold.
A normal GCS during the lucid interval is not reassurance; the patient can herniate within hours.
A lumbar puncture with a mass lesion can precipitate herniation and is contraindicated.
Item 536129
Clinical Practice: Head and Neck · 31 items
A patient with a C6 spinal cord injury is prescribed midodrine for orthostatic hypotension. The nurse should schedule the doses
Answer and why, all 4 options
A bedtime dose has no orthostatic benefit and maximizes supine hypertension during sleep.
Midodrine raises blood pressure for a few hours to counter orthostatic hypotension, but it can cause dangerous supine hypertension. Doses are given during the day when the patient is upright, with the last dose about 4 hours before bed.
Taking it before lying down creates supine hypertension while giving no help with upright blood pressure.
Overnight doses add supine hypertension without benefit, since the patient is lying down.
Item 536141
Clinical Practice: Head and Neck · 31 items
The nurse is teaching a patient being discharged after a concussion with a normal head CT. Which statement shows understanding?
Answer and why, all 4 options
Alcohol can worsen concussion symptoms, impair judgment, and mask signs of deterioration, so it is avoided during recovery. This statement shows the patient understands the teaching.
Keeping the patient awake is unnecessary; rest helps recovery, and a companion can check on the patient instead.
Aspirin increases bleeding risk after head injury; acetaminophen is the usual choice.
Concussion slows reaction time and attention, so driving right after the injury is unsafe.
Item 536148
Clinical Practice: Head and Neck · 31 items
An 18-month-old fell down several stairs. Which finding requires the MOST immediate report to the provider?
Answer and why, all 4 options
New drowsiness and slowed responses in a toddler after a fall can signal rising intracranial pressure, and young children cannot describe symptoms. This change is reported at once.
Immediate crying is a normal reaction and suggests the child did not lose consciousness.
Wanting to feed suggests normal behavior and alertness.
Frontal bruises are low risk; scalp hematomas in the temporal, parietal, or occipital areas are more concerning in young children.
Item 536167
Clinical Practice: Head and Neck · 31 items
A patient with maxillomandibular fixation has lost 3 kg in the week after surgery. The nurse should anticipate
Answer and why, all 4 options
Clear liquids contain little protein or calories and will deepen the weight loss.
Restricting fluids worsens dehydration and calorie deficit; drooling is managed with suction and positioning.
Removing fixation early disrupts healing of the fracture; weight loss is addressed with nutrition, not by releasing the jaw.
With the jaws wired shut, the patient can take only liquids, and weight loss shows intake is not meeting needs. Calorie- and protein-dense liquid supplements through a syringe or straw, with a dietitian consult, restore intake.
Item 536202
Clinical Practice: Head and Neck · 31 items
A patient with sickle cell trait has a traumatic hyphema, and intraocular pressure is rising. Which order should the nurse question?
Answer and why, all 4 options
Elevating the head lets blood settle inferiorly and clear the visual axis; it is appropriate.
Acetaminophen is preferred because it does not impair platelets; NSAIDs and aspirin are the agents to avoid.
A rigid shield protects the injured globe and is standard hyphema care.
Carbonic anhydrase inhibitors acidify the aqueous humor, which promotes sickling of red cells in the anterior chamber and blocks outflow, raising pressure further. In patients with sickle cell trait or disease and a hyphema, acetazolamide is avoided.
Item 2100481
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Where neuro trauma answers go wrong
Hyperventilating "to protect the brain." The Brain Trauma Foundation 4th edition recommends against prolonged prophylactic hyperventilation; a short period is a bridge for signs of herniation only, and normal ventilation is the target otherwise.
Old thresholds. The same guideline treats ICP above 22 mm Hg, aims for a cerebral perfusion pressure of 60–70, and sets the systolic floor by age: at least 100 mm Hg at 50–69 years, at least 110 at 15–49 and over 70. Options built on 20 and 90 come from older editions.
Steroids. Not for brain injury, where the CRASH trial found higher mortality, and not recommended for acute cord injury in the 2013 AANS/CNS guideline.
A tube through the nose. With a suspected basilar skull or midface fracture, gastric and tracheal tubes go through the mouth.
Calling every hypotensive cord injury neurogenic. Lost sympathetic tone gives neurogenic shock its picture: hypotension, warm dry skin and a heart rate that fails to climb. Hypotension with tachycardia after trauma is bleeding until proven otherwise; spinal shock is the temporary loss of reflexes below the level, not a blood pressure state.
One exact MAP target for the cord. The 2013 AANS/CNS guideline set 85–90 mm Hg for the first week; the 2024 AO Spine guideline accepts a range with a lower floor. A single number is rarely the point of a question; avoiding hypotension is.
Treating the pressure before the cause in autonomic dysreflexia. With an injury at T6 or above, raise the head of the bed, then hunt for the noxious stimulus below the injury (a full bladder, impacted bowel, tight clothing) before reaching for a drug.
Zones as the rule for neck exploration. Current Western Trauma Association guidance manages penetrating neck injury by hard signs and CT angiography rather than by which zone was entered.
Mechanical eye injuries are listed here under maxillofacial and neck trauma. Chemical burns of the eye are listed with burns, under special populations.
Are concussions part of this domain?
Yes. A concussion is a mild traumatic brain injury, and BCEN lists traumatic brain injury here without limiting it by severity.