The nurse is caring for a patient who had a serious head injury.
The patient has recovered enough to be transferred to a rehabilitation facility.
Which of the following rehabilitation goals would be most appropriate for the patient?
The patient will recall events from childhood.
The patient will return to work as a corporate attorney.
The patient will actively participate in the rehabilitation process as appropriate.
The patient will demonstrate improved motor coordination within two weeks.
The Correct Answer is C
Choice A rationale
Childhood memory recall reflects cognitive functioning but is unrelated to the patient's rehabilitation involvement, which focuses on regaining lost functional capacities following injury. Such a goal lacks immediate functional relevance.
Choice B rationale
Returning to work as a corporate attorney may be an eventual aim but depends on higher cognitive recovery levels and is too specific. Early rehabilitation outcomes focus on participation in the recovery process.
Choice C rationale
Active participation indicates readiness and willingness to engage in therapies essential for regaining lost functions. It aligns with goals for a transition from acute care to rehabilitation emphasizing functional improvement.
Choice D rationale
Motor coordination improvements require therapy timelines extending beyond two weeks. Such a rigid short-term goal undermines individualized rehabilitation focusing on measurable progress over more realistic durations.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Hypertension is not the primary concern in cervical spinal cord injuries at C-3, where respiratory compromise due to diaphragm paralysis is the leading cause of complications or mortality.
Choice B rationale
Bradycardia can occur due to vagal stimulation in spinal injuries but is less life-threatening compared to the respiratory compromise caused by diaphragmatic paralysis.
Choice C rationale
Sepsis may develop in spinal cord injury patients, particularly from infections like pneumonia or urinary tract infections, but respiratory failure is the most acute concern at C-3.
Choice D rationale
Respiratory compromise occurs due to impaired diaphragm function at C-3, making it the primary cause of morbidity or mortality, necessitating prompt respiratory support and monitoring.
Correct Answer is C
Explanation
Choice A rationale
Subarachnoid hemorrhage is less likely given the sudden decrease in consciousness. This type of injury typically results in severe headache or focal neurological deficits, not rapid mental decline.
Choice B rationale
Diffuse axonal injury usually presents with persistent unconsciousness rather than sudden deterioration. It results from widespread shearing forces and is less likely with the reported history.
Choice C rationale
Epidural hematoma often presents with a lucid interval followed by sudden neurological decline, as described in this case. Rapid accumulation of blood between the dura and skull can compress brain tissue.
Choice D rationale
Subdural hematoma tends to cause gradual neurological deterioration rather than a sudden decrease in Glasgow Coma Scale. This occurs due to slower venous bleeding. .
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