Nokea
When assessing a patient with a traumatic brain injury, the nurse notes that his memory is improving. The nurse should explain to the family that what other symptom may occur with memory improvement?
- A. Decrease in learning ability
- B. Depression
- C. Anger
- D. Increased concentration
Correct Answer: B
Rationale: Generally, the more memory improves in a patient with a brain injury, the more the patient becomes depressed.
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The rehabilitation nurse can use basic rehabilitation skills regardless of the origin of the disability. What intervention would be effective for a person with arthritis, a person with a brain injury, or a person with a spinal cord injury?
- A. Encouraging large fluid intake
- B. Seeking spiritual support from a higher being
- C. Using the spouse as a support system
- D. Positioning to maintain alignment
Correct Answer: D
Rationale: Alignment preservation is an implementation that is appropriate for a variety of rehabilitation patients, regardless of the origin of their disability.
The nurse who is part of a team focused on restoring an individual to the fullest physical, mental, social, vocational, and economic capacity is practicing what type of nursing?
- A. Holistic nursing
- B. Conscientious nursing
- C. Rehabilitation nursing
- D. Comprehensive nursing
Correct Answer: C
Rationale: Rehabilitation is the process of restoring an individual to the fullest physical, mental, social, vocational, and economic capacity of which he or she is capable.
What should a nurse explain to a patient as a cause of triggering autonomic dysreflexia?
- A. Loud sound
- B. Distended bladder
- C. Leg cramp
- D. Sudden chilling
Correct Answer: B
Rationale: Patients with spinal cord lesions above T5 may experience sudden and extreme elevations in blood pressure caused by a reflex action of the autonomic nervous system. It is produced by stimulation of the body below the level of the injury, usually by a distended bladder from a blocked catheter. Any stimulation can produce the syndrome, including constipation, diarrhea, sexual activity, pressure injuries, position changes (from lying to sitting), and even wrinkles in clothing or bed sheets.
The nurse used a diagnosis of impaired cognition for a 40-year-old patient with a brain injury. Which assessment data would support the diagnosis?
- A. Frequently becomes violent.
- B. Becomes easily fatigued.
- C. Is depressed.
- D. Cannot add three numbers in his head.
Correct Answer: D
Rationale: Impaired cognition includes problems in thinking, impaired concentration, and impaired information processing.
What should the nurse do to decrease the potential for a deep vein thrombosis (DVT) in a patient who is a paraplegic from a spinal cord injury?
- A. Massage the patient's legs daily.
- B. Perform passive range-of-motion exercises.
- C. Encourage frequent warm baths.
- D. Allow the patient's legs to dangle for a period of 10 minutes several times a day.
Correct Answer: B
Rationale: DVTs are a problem for patients with a spinal cord injury. Passive range-of-motion exercises manipulate the muscles, which improves venous return, reducing the probability of DVT.