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 B

Explanation

Choice A rationale

Administering oxygen at 6 liters per minute via nasal cannula risks hypercapnia in a client with emphysema due to impaired CO2 elimination. Oxygen should be titrated to maintain safe saturation levels, usually 88–92%.

Choice B rationale

Ipratropium is a bronchodilator that safely alleviates airway constriction in emphysema without systemic cardiovascular effects, making it suitable for a client with coronary artery disease and chronic obstructive pulmonary conditions.

Choice C rationale

Propranolol is contraindicated in emphysema due to its beta-blocking effects, which may exacerbate bronchoconstriction and reduce respiratory function, posing a significant risk to the client’s health.

Choice D rationale

Organic herbal supplements lack evidence-based safety and efficacy, especially in complex medical conditions like coronary artery disease and emphysema. They can also interact adversely with prescribed medications.

A. Elevate the head of the bed 30-45 degrees. B. Perform serial neurologic assessments while hospitalized. C. Suction frequently to prevent development of pneumonia. D. Administer sedatives/pain medications per orders. E. Stimulate the patient with TV, music, lights, and family at bedside.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Elevating the head 30-45 degrees aids in venous drainage and reduces intracranial pressure. It also prevents cerebral edema by improving cerebrospinal fluid outflow without compromising cerebral perfusion.

Choice B rationale

Serial neurological assessments help monitor for changes in intracranial pressure, enabling early intervention. They ensure timely recognition of symptoms indicating worsening pressure or neurological deterioration.

Choice C rationale

Frequent suctioning increases intracranial pressure due to stimulation of the vagus nerve, leading to coughing or gagging. It can also induce hypoxia, further exacerbating intracranial pressure.

Choice D rationale

Administering sedatives and pain medications reduces cerebral metabolic rate and sympathetic stimulation, which in turn prevents spikes in intracranial pressure. It also helps prevent agitation and discomfort in the patient.

Choice E rationale

Stimulating the patient with TV, music, lights, and family increases sensory input, which can elevate intracranial pressure. Overstimulation can cause agitation, raising intracranial pressure further.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has a past medical history of coronary artery disease and emphysema.The nurse knows which agent is safest to give?

Correct Answer is B

Explanation

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.)

Correct Answer is ["A","B","D"]

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?