Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
43. Which findings should indicate to a nurse that a traumatic brain injury has resulted in brain death? Select all that apply.
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
43. Which findings should indicate to a nurse that a traumatic brain injury has resulted in brain death? Select all that apply.
. No response to the cold caloric test.
. Glasgow Coma Scale (GCS) score of 6.
. Electroencephalogram (EEG) tracing is flat.
. Positive gag reflex.
. No spontaneous respirations.
Test-Taking Tip
Remember that brain death is an irreversible loss of all brain functions.
Content Area: Adult Health, Neurological; Integrated Process: Nursing Process, Analysis; Cognitive Level: Application; Client Need/Subneed: Physiological Integrity/Physiological Adaptation/Alterations in Body Systems
Pre-Test 1 and 2: Introduction to Special Questions Based on Official NCLEX-RN[®]
. . .
Answer 1 is correct because the cold caloric test is a test of the oculovestibular reflex, and absence of this reflex indicates severe brainstem injury. Answer 2 is incorrect because a GCS of less than 7 indicates coma, not brain death. Answer 3 is correct because a flat EEG indicates the absence of electrical activity in the brain. Answer 4 is incorrect because a gag reflex would indicate brain function. Answer 5 is correct because the absence of spontaneous respirations indicates the absence of brain function.