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.

Answer and Explanation

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.

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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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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?

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Naxlex Comprehensive Predictor Exams

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Explanation

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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?