The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

Initiate a 1:1 observation status

Point out the behavior as unacceptable

Ask the patient why they are behaving that way

Have the patient return to his room

Answer and Explanation

The Correct Answer is B

A. 1:1 observation may be excessive unless the behavior is persistent and unmanageable.

B. Pointing out the behavior as unacceptable provides immediate feedback and helps the patient understand social boundaries, which can be challenging post-brain injury. This approach is direct and respectful, focusing on redirection rather than punishment.

C. Asking why may not be effective, as the patient may lack insight into their behavior due to the brain injury.

D. Having the patient return to their room could seem punitive and does not address the need for behavior modification.

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Correct Answer is C

Explanation

A. Soft restraints are not recommended during a seizure and can cause harm to the patient.

B. Placing anything in the mouth during a seizure can lead to injury or airway obstruction and is contraindicated.

C. Turning the patient on their side helps to maintain an open airway and prevent aspiration; staying with the patient ensures ongoing monitoring.

D. Leaving the patient alone to seek help is unsafe, as it leaves the patient unmonitored during the seizure.

A. "Using three drugs at the same time enhances suppression of viral replication." B. "If the virus becomes resistant to this combination, I will be switched to another combination of medications." C. "Because the combination of medications kills the virus, I can stop taking the medications." D. "My CD4 count should increase with this medication regimen."

Correct Answer is C

Explanation

A. This is a correct statement, as using multiple drugs helps to reduce the likelihood of resistance and enhances viral suppression.

B. This is accurate; if resistance develops, alternative medications or combinations can be considered.

C. This statement indicates a misunderstanding. Antiretroviral medications do not kill the virus; they suppress its replication. Lifelong adherence to antiretroviral therapy is necessary to manage HIV and prevent viral rebound.

D. Correct, as an effective regimen should lead to an increase in CD4 count and improved immune function.

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The nurse on the brain injury unit observes a patient who displays inappropriate sexual behavior. What would be the best response by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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