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 D

Explanation

A. Antibiotics may be necessary if infection is confirmed, but this is not the priority action.

B. Applying a pressure dressing could increase intracranial pressure or worsen the injury.

C. IV fluids can be helpful in managing shock but are not directly related to CSF leakage management.

D. Yellowish fluid from the ear, which creates a "halo" or yellow ring around it on gauze, may indicate cerebrospinal fluid (CSF) leakage. This is a sign of a potential skull fracture and requires prompt provider notification. Allowing the fluid to drain and collecting it can provide necessary information about the injury.

A. Notify the physician of this finding B. Elevate the limb on two pillows C. Cover the limb with a blanket D. Reposition the limb and reassess

Correct Answer is A

Explanation

A. A cold, pulseless foot indicates compromised blood flow, a medical emergency following an arteriogram. The nurse should immediately notify the physician to address potential vascular occlusion.

B. Elevating the limb can further impair circulation if blood flow is already compromised.

C. Covering the limb will not address the underlying issue of impaired circulation.

D. Repositioning may delay timely intervention in what may be a vascular emergency.

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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 caring for a trauma patient with suspected brain injury. The nurse notices a yellow stain around fluid dripping from the patient's ear. The nurse's priority intervention will be as follows:

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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