Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

Being increasingly non-compliant with therapeutic care plans.

Playing chess with fellow patients within one week of admission.

Difficulty planning and organizing thoughts and behaviors.

Ability to process multiple pieces of information at the same time.

Answer and Explanation

The Correct Answer is C

Choice A rationale

Chronic head injuries can impair judgment, leading to non-compliance with care plans due to reduced awareness and impulse control. However, non-compliance alone is not a definitive behavioral characteristic of chronic head injury.

Choice B rationale

Rapid engagement in cognitively demanding tasks like chess within a week suggests intact neurological and cognitive function, which contradicts the expected deficits in chronic head injury patients.

Choice C rationale

Chronic head injuries commonly affect the frontal lobe, impairing executive functions such as planning, organizing, and controlling thoughts and behaviors. These deficits result from damage to neural pathways crucial for these cognitive tasks.

Choice D rationale

The ability to process multiple pieces of information simultaneously requires intact cognitive functioning, typically disrupted in chronic head injuries due to neuronal damage, particularly in the prefrontal cortex.

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Correct Answer is D

Explanation

Choice A rationale

Squeezing the nurse’s hand on verbal request suggests neurological improvement and does not warrant urgent intervention, indicating preserved motor response and cognition.

Choice B rationale

Following commands with repetition/prompting shows mild cognitive delay or reduced processing but does not represent deterioration or life-threatening concern needing immediate action.

Choice C rationale

Purposeful movement to sternal rub implies intact motor response to noxious stimuli. It does not indicate significant neurologic worsening requiring urgent intervention.

Choice D rationale

Extending extremities in response to painful stimuli, known as decerebrate posturing, is a severe neurologic deficit indicating brainstem dysfunction and requires immediate nursing intervention.

A. Frequency of urination. B. Dysuria. C. Flank pain and fever. D. Pyuria and hematuria.

Correct Answer is C

Explanation

Choice A rationale

Monitoring frequency of urination indicates bladder involvement, often related to cystitis. However, it does not indicate ascending progression to the kidneys, which is more severe and requires additional symptoms.

Choice B rationale

Dysuria, or painful urination, typically signifies lower urinary tract infection rather than progression to upper urinary tract infection, such as pyelonephritis. It is not specific to kidney involvement.

Choice C rationale

Flank pain and fever are hallmark symptoms of pyelonephritis, indicating ascending progression of infection from the bladder to the kidneys. These symptoms signal systemic involvement and require immediate medical attention.

Choice D rationale

Pyuria and hematuria are signs of bladder infection but do not indicate progression to kidney infection. These are specific to inflammation or infection in the lower urinary tract.

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Which behaviors by the patient diagnosed with a chronic head injury would the nurse expect to find?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a patient diagnosed with a traumatic head injury secondary to a work accident.In the morning assessment, the patient opened his eyes in response to noxious stimuli.Two hours later, what assessment finding would warrant immediate action by the nurse? The patient:

Correct Answer is D

Explanation

A nurse is caring for a client who has had repeated instances of cystitis.When considering possible ascending progression of the infection, the client should be taught to monitor for:

Correct Answer is C

Explanation

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?

A client's daughter asks the nurse for assistance in communicating with her mother who has sensorineural hearing loss.Which point is appropriate for the nurse to teach?

The nurse has established a goal to maintain intracranial pressure (ICP) within the normal range for a patient with an acute head injury.Which actions should the nurse take to achieve this goal? (Select All that Apply.)

A client is to receive 250 mL of IV fluid over 90 minutes by gravity. The drop factor on the IV tubing is 20 gtts/mL. How many gtts/min should be administered?

The nurse is preparing to administer 1600 mL of total parental nutrition (TPN) over 24 hours. The nurse should set the IV pump to deliver how many mL/hr?

A nurse is the first person on the scene of a motor vehicle accident.The victim was the driver and is in the driver's seat unconscious.The driver is breathing, has a pulse, and has minor lacerations on the head and face.What action should the nurse implement first?

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