The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

Initiate a 1:1 observation status

Point out the behavior as unacceptable

Ask the patient why they are behaving that way

Have the patient return to his room

Answer and Explanation

The Correct Answer is B

A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.

B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.

C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.

D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.

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Correct Answer is D

Explanation

A. A ketogenic diet does not focus on high sodium or high sugar, as high sugar intake would increase carbohydrate levels.

B. A ketogenic diet is high in fat rather than low in fat.

C. High carbohydrates are avoided in a ketogenic diet, as the goal is to limit carbohydrates to promote ketone production.

D. The ketogenic diet consists of high fat and low carbohydrates, which helps to manage seizure activity by altering the brain's energy source to ketones rather than glucose.

A. Elevate the head of the bed, loosen clothing, and check the urinary catheter for obstruction B. Elevate the head of the bed and apply a cool compress to the forehead C. Place in Semi-Fowler's position and establish IV access D. Establish IV access, apply 2 liters of nasal oxygen, and contact the health care provider

Correct Answer is A

Explanation

A. Elevating the head of the bed, loosening clothing, and checking for urinary catheter obstruction are key steps to lower blood pressure and relieve triggers of autonomic dysreflexia, a potentially life-threatening condition.

B. A cool compress may provide comfort but does not directly address the primary triggers or symptoms of autonomic dysreflexia.

C. Semi-Fowler's position is insufficient compared to a full 90-degree sitting position, which helps reduce blood pressure.

D. IV access and oxygen may be required if symptoms do not resolve, but immediate actions focus on relieving the cause of dysreflexia.

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The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The patient who is diagnosed with a seizure disorder is prescribed a ketogenic diet. The nurse knows that the patient understands the teaching when they state, "My diet will include:

Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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