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 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. T 92.5 F (33.6 C), BP 90/64, HR 80, RR 14, 02 Sat 97% Room Air B. T 98.7 F (36.4 C), BP 220/46, HR 30, RR 6, O2 Sat 98% Room Air C. T 98.6 F (37 C), BP 200/94, HR 90, RR 18, 02 Sat 100% Room Air D. T 103.1 F (39.5 C), BP 82/50, HR 132, RR 30, O2 Sat 99% Room Air

Correct Answer is B

Explanation

A. The low blood pressure (90/64) may indicate hypovolemia or shock but is not specific for ICP concerns.

B. This set of vital signs is concerning due to the extremely high blood pressure (220/46) combined with a very low heart rate (30) and low respiratory rate (6), which can indicate an autonomic response to increased ICP, potentially leading to Cushing's triad (hypertension, bradycardia, and irregular respirations).

C. Although the blood pressure is high (200/94), the heart rate is normal and the respiratory rate is stable, making this less alarming compared to option B.

D. The elevated temperature and abnormal heart rate (132) indicate potential fever and tachycardia, but the blood pressure (82/50) is low and does not directly indicate increased ICP.

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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

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Correct Answer is C

Explanation

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Correct Answer is B

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