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

Hypertension is not the primary concern in cervical spinal cord injuries at C-3, where respiratory compromise due to diaphragm paralysis is the leading cause of complications or mortality.

Choice B rationale

Bradycardia can occur due to vagal stimulation in spinal injuries but is less life-threatening compared to the respiratory compromise caused by diaphragmatic paralysis.

Choice C rationale

Sepsis may develop in spinal cord injury patients, particularly from infections like pneumonia or urinary tract infections, but respiratory failure is the most acute concern at C-3.

Choice D rationale

Respiratory compromise occurs due to impaired diaphragm function at C-3, making it the primary cause of morbidity or mortality, necessitating prompt respiratory support and monitoring.

A. Encourage client to tuck chin when swallowing. B. Ensure that any protein is pureed prior to feeding the client. C. Assess client's preferences and have their family leave snacks at their bedside. D. Turn on music to promote client's relaxation.

Correct Answer is A

Explanation

Choice A rationale

Chin tuck alters airway mechanics, reducing aspiration risk by improving epiglottic closure and minimizing passage of food into respiratory pathways.

Choice B rationale

Pureeing protein may ease swallowing but does not inherently reduce aspiration risk compared to specific swallowing techniques.

Choice C rationale

Unsupervised snack access increases aspiration risk, as dysphagia requires monitored intake to prevent respiratory complications.

Choice D rationale

Background music may provide relaxation but does not scientifically mitigate aspiration risks in dysphagia-related interventions. .

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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

The nurse is caring for a patient in the acute care setting with a spinal cord injury at the level of C-3. The nurse understands that the main cause of complications or death related to this injury includes:

Correct Answer is D

Explanation

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Correct Answer is A

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?