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 A
Explanation
Choice A rationale
Stabilizing the cervical spine prevents further spinal injury in case of vertebral damage, which is a priority when managing trauma patients until specialized medical care becomes available.
Choice B rationale
While controlling bleeding is essential, it is secondary to stabilizing the cervical spine since the airway and neurological protection take precedence in trauma protocols.
Choice C rationale
The head tilt chin lift method should not be used if cervical spine injury is suspected, as it may exacerbate potential damage to the vertebrae or spinal cord.
Choice D rationale
While not moving the victim is critical, stabilization of the cervical spine is the primary intervention to prevent further injury before emergency assistance arrives.
Correct Answer is B
Explanation
Choice A rationale
Checking serum drug levels provides insight into compliance and effectiveness but doesn’t address immediate seizure cessation, prioritizing treatment over diagnostic assessment.
Choice B rationale
Administering lorazepam IV halts seizure activity quickly by enhancing GABA activity, calming neuronal excitation, and stabilizing the patient’s condition, reducing potential complications.
Choice C rationale
Monitoring vitals like blood pressure and heart rate is essential but doesn’t directly address convulsive activity, which requires immediate pharmacological intervention to prevent status epilepticus progression. .
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