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 A

Explanation

A. A pH within the normal range, a PaCO2 within the normal range, and an improved PaO2 level suggest effective treatment for an asthma attack, indicating adequate gas exchange and resolution of respiratory distress.

B. A pH of 7.52 and low PaCO2 suggest respiratory alkalosis, which can occur with hyperventilation and may indicate overventilation rather than effective asthma treatment.

C. This result shows elevated PaCO2 and borderline low PaO2, indicating ongoing respiratory acidosis and hypoxia, suggesting the treatment is not yet effective.

D. This ABG result shows low pH, indicating acidosis, and a low bicarbonate level, which may indicate metabolic acidosis rather than effective asthma management.

A. Take this medication with food or milk B. Get potassium levels drawn periodically C. Increase intake of green vegetables D. Use salt substitute for cooking

Correct Answer is B

Explanation

A. While taking some medications with food or milk can help with absorption, this is not a specific requirement for lisinopril.

B. Lisinopril, an ACE inhibitor, can lead to elevated potassium levels. Periodic monitoring of potassium levels is essential to prevent hyperkalemia, a potentially dangerous side effect.

C. Increasing intake of green vegetables is generally healthy but does not directly impact lisinopril's effects.

D. Many salt substitutes contain potassium, which could elevate potassium levels further when taken with ACE inhibitors like lisinopril, posing a risk for hyperkalemia.

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ABG Value	Normal Range
pH	7.35- 7.45
PaCO2	35-45 mm Hg
HCO3	22-25 mEq/L
Base excess	-2 to +2
PaO2	80-95 mm Hg
SaO2	>95%

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

Correct Answer is A

Explanation

The nurse is caring for a patient who will be discharged with a prescription for lisinopril. What discharge teaching should be provided related to this medication?

Correct Answer is B

Explanation

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