A Patient with a Brain Injury Is Not Able to Respond

question 53

Multiple Choice

A patient with a brain injury is not able to respond appropriately to sensory stimulation.What should the nurse do to ensure that this patient does not develop skin breakdown? (Select all that apply.)

• A) Protect bony prominences
• B) Assess the skin every 2 hours
• C) Moisturize the skin as needed
• D) Apply paper tape over wounds
• E) Turn and reposition every 2 hours

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Definitions:

Privacy

The right of individuals to keep their personal information out of public view and to have control over their own personal data.

Reward Motivation

Refers to the drive or impulse to engage in or perform a task due to the incentives or rewards that follow the completion of the task.

Timeliness

The quality of occurring at a favorable or opportune time, especially in completing tasks, delivering information, or making decisions.

Availability

The state of being accessible and ready for use.