The nurse and the nursing assistive personnel are assisting a postoperative patient to turn in bed. To assist in minimizing discomfort, which instruction should the nurse provide to the patient?

Correct Answer: D

Rationale: The correct answer is D because placing the hand over the incision provides support and stability, reducing discomfort during the turning process. This action helps prevent unnecessary strain on the incision site and promotes healing. A, B, and C are incorrect because closing eyes or thinking about something pleasant, holding breath, and grabbing shoulders do not provide physical support or address the specific discomfort related to postoperative turning in bed.

Correct Answer: A

Rationale: Step 1: Cheyne-Stokes respirations suggest dysfunction in the cerebral cortex and upper brainstem. Step 2: Increasing blood pressure and decreasing, reactive pulse rate indicate a raised intracranial pressure affecting the cortex and upper brainstem. Step 3: Compression in the cortex and upper brainstem can lead to autonomic dysregulation causing the observed symptoms. Step 4: Midbrain, medulla oblongata, and lower brainstem are not directly associated with the symptoms described. Summary: The correct answer is A because the symptoms presented are indicative of dysfunction in the cortex and upper brainstem, while the other choices do not align with the specific symptoms observed in the patient.

Correct Answer: C

Rationale: The correct answer is C. In a complete spinal cord transection, there is total absence of pain, sensation, and movement below the level of injury due to complete disruption of nerve pathways. This results in paralysis below the injury site. A is incorrect because a complete transection would result in total loss of pain, sensation, and movement, not just some loss of movement. B is incorrect as bradycardia and loss of vascular tone are indicative of autonomic dysreflexia, typically seen in spinal cord injuries above T6, not a complete transection. D is incorrect as right-sided paralysis with decreased sensation on the opposite side does not align with the expected presentation of a complete spinal cord transection.

Correct Answer: C

Rationale: The correct answer is C (19 to 23 centimeters). The proper depth marking for an orotracheal intubation in an average-sized adult is typically around 21 centimeters at the teeth for females and 23 centimeters for males. This positioning ensures that the tip of the endotracheal tube is approximately 2 to 3 cm above the carina, allowing for adequate ventilation while minimizing the risk of complications such as mainstem bronchus intubation. Choices A, B, and D are incorrect as they do not fall within the appropriate depth range for proper positioning of the endotracheal tube. Option A is too shallow, option B is too deep, and option D is also too deep and carries a risk of complications.

Correct Answer: C

Rationale: The correct answer is C because the patient lost consciousness immediately following the injury, then quickly regained consciousness, but lost consciousness again just before calling 911. This pattern of lucid intervals followed by a deteriorating level of consciousness is indicative of an epidural hematoma. The initial loss of consciousness is due to the initial trauma causing bleeding between the skull and the dura mater, leading to increased intracranial pressure. The temporary regaining of consciousness occurs when the hematoma temporarily stops expanding before resuming bleeding, causing a decline in consciousness again. Summary: A: A 'goose egg' noted on the patient's head is more indicative of a scalp hematoma or soft tissue injury, not necessarily an epidural hematoma. B: The patient being unconscious throughout transport could indicate a severe brain injury, but the specific pattern described in option C is more characteristic of an epidural hematoma. D: A sudden, severe headache may be a symptom of various head injuries, but it is