After having a craniectomy and left anterior fossae incision, a ...

[renzo156]

After having a craniectomy and left anterior fossae incision, a 64-year-old patient has a nursing diagnosis of impaired physical mobility related to decreased level of consciousness and weak-ness. An appropriate nursing intervention is to
 
  a. cluster nursing activities to allow longer rest periods.
  b. turn and reposition the patient side to side every 2 hours.
  c. position the bed flat and log roll to reposi-tion the patient.
  d. perform range-of-motion (ROM) exercises every 4 hours.

Question 2

A 42-year-old patient who has bacterial meningitis is disoriented and anxious. Which nursing ac-tion will be included in the plan of care?
 
  a. Encourage family members to remain at the bedside.
  b. Apply soft restraints to protect the patient from injury.
  c. Keep the room well-lighted to improve patient orientation.
  d. Minimize contact with the patient to de-crease sensory input.

[zhanghao]

Answer to Question 1

ANS: D
ROM exercises will help prevent the complications of immobility. Patients with anterior crani-otomies are positioned with the head elevated. The patient with a craniectomy should not be turned to the operative side. When the patient is weak, clustering nursing activities may lead to more fatigue and weakness.

Answer to Question 2

ANS: A
Patients with meningitis and disorientation will be calmed by the presence of someone familiar at the bedside. Restraints should be avoided because they increase agitation and anxiety. The pa-tient requires frequent assessment for complications. The use of touch and a soothing voice will decrease anxiety for most patients. The patient will have photophobia, so the light should be dim.

[renzo156]

TYSM

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