The nurse is caring for a patient who had a serious head injury. The patient has recovered enough to be to be transferred to a rehabilitation facility. Which of the following rehabilitation goals would be most appropriate for the patient? The patient will:

display preinjury personality traits.

actively participate in the rehabilitation process as appropriate.

return to work as a corporate attorney.

recall events from childhood.

Answer and Explanation

The Correct Answer is B

A. Expecting a patient to display preinjury personality traits may not be feasible, as head injuries can lead to permanent personality changes.

B. Actively participating in rehabilitation is a realistic goal that focuses on the patient's engagement in the recovery process, which can improve functional outcomes.

C. Returning to a specific job, such as a corporate attorney, may not be a realistic goal initially and depends on the extent of cognitive recovery.

D. Recalling childhood events is not a priority goal in rehabilitation; functional and recovery-focused goals are more relevant.

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Correct Answer is C

Explanation

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

A. Encourage the patient to cough to expectorate secretions B. Elevate the head of the bed to 30-45 degrees C. Stimulate the patient with active range of motion exercises D. Perform serial neurologic assessments while hospitalized E. Contact the healthcare provider if the ICP is sustained between 30-40mmHg

Correct Answer is ["B","D","E"]

Explanation

A. Coughing can increase ICP by increasing intrathoracic pressure and should be minimized in patients with head injuries.

B. Elevating the head of the bed to 30-45 degrees promotes venous drainage from the head, reducing ICP.

C. Active stimulation can increase ICP and is generally avoided in patients with acute head injuries.

D. Serial neurologic assessments help monitor any changes in the patient’s condition and ICP, allowing for timely intervention.

E. Sustained ICP levels between 30-40 mmHg are significantly elevated and require immediate communication with the healthcare provider, as they are above the normal range and could lead to further complications

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The nurse is caring for a patient who had a serious head injury. The patient has recovered enough to be to be transferred to a rehabilitation facility. Which of the following rehabilitation goals would be most appropriate for the patient? The patient will:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing the morning assessment on a patient. The patient suddenly screams loudly and begins to have a generalized tonic/clonic type seizure. What is the priority nursing intervention?

Correct Answer is C

Explanation

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for the patient with an acute head injury. Which action(s) should the nurse take to achieve this goal? (SELECT ALL THAT APPLY)

Correct Answer is ["B","D","E"]

Explanation

The nurse suspects a subarachnoid hemorrhage in a patient admitted to the emergency department. Which of the following symptoms is commonly seen in a patient diagnosed with a subarachnoid hemorrhage?

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