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 D

Explanation

A. Using a draw sheet may cause twisting, which can compromise spinal alignment.

B. Asking the patient to assist may risk further spinal injury.

C. Turning hips and shoulders separately risks disrupting spinal alignment, making this an unsafe approach.

D. Log rolling is the safest way to turn a patient with a spinal cord injury, maintaining spinal alignment and preventing further injury. It requires one person to stabilize the head while others turn the body as a single unit.

A. Sharing eating utensils B. Sharing a razor C. Kissing on the mouth D. Using the same toilet

Correct Answer is B

Explanation

A. Sharing eating utensils does not transmit HIV, as the virus is not spread through saliva.

B. Sharing razors is a high-risk activity for transmitting HIV because it can involve direct blood-to-blood contact if the razor causes cuts.

C. HIV transmission through kissing is highly unlikely due to low levels of the virus in saliva.

D. HIV cannot be spread through shared toilets, as the virus does not survive on surfaces and is not spread through casual contact.

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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 D

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