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: "Place your hand over your incision." This instruction is correct because it encourages the patient to provide support and gentle pressure to the incision area while turning, which can help reduce discomfort and provide a sense of security. This action can also prevent accidental disruption of the incision site. A: "Close your eyes and think about something pleasant." This choice does not provide any physical support or guidance for the patient during the turning process. B: "Hold your breath and count to three." This instruction is incorrect as holding one's breath can increase intra-abdominal pressure and potentially cause discomfort during the turning maneuver. C: "Grab my shoulders with your hands." This choice does not address the specific need to provide support to the incision area and may not be the most effective way to minimize discomfort during turning.

Correct Answer: A

Rationale: The correct answer is A: Cortex and upper brainstem. When a patient with increased intracranial pressure exhibits Cheyne-Stokes respirations, increasing blood pressure, and decreasing, reactive pulse rate, it indicates dysfunction at the level of the cortex and upper brainstem. Cheyne-Stokes respirations are associated with damage at the level of the cortex. Increasing blood pressure and decreasing, reactive pulse rate are signs of raised intracranial pressure affecting the upper brainstem. Dysfunction at the midbrain region or lower portion of the brainstem would present with different symptoms, such as pinpoint pupils or abnormal posturing. The medulla oblongata is responsible for controlling vital functions like breathing and heart rate, so dysfunction in this region would present with more severe respiratory and cardiovascular symptoms.

Correct Answer: C

Rationale: The correct answer is C because a complete spinal cord transection results in total absence of pain, sensation, and movement below the point of injury due to the interruption of all nerve pathways. This is known as complete paralysis. Choices A and D describe incomplete injuries, where some function is preserved. Choice B is incorrect as bradycardia and loss of vascular tone are associated with injuries at higher spinal cord levels, such as cervical injuries, not complete transections.

Correct Answer: C

Rationale: The correct answer is C (19 to 23 centimeters) because the correct depth marking for an adult orotracheal intubation is typically at 21 to 23 centimeters at the teeth or 19 to 21 centimeters at the lips. Placing the tube 2 to 3 cm above the carina ensures adequate ventilation without the risk of the tube being too deep or too shallow. Choices A, B, and D are incorrect because they are outside the recommended depth range for adult orotracheal intubation, which can lead to complications such as inadequate ventilation, aspiration, or trauma to surrounding structures.

Correct Answer: C

Rationale: The correct answer is C because the patient experiencing a loss of consciousness immediately following the injury, regaining consciousness quickly, and then losing consciousness again is indicative of an epidural hematoma. This pattern is known as the "lucid interval," where the initial impact causes bleeding between the skull and dura mater, leading to a temporary improvement in symptoms before the hematoma expands, causing increased intracranial pressure and loss of consciousness. Choice A (Goose egg' noted on patient's head) is not specific to epidural hematoma and can occur in various head injuries. Choice B (The patient is unconscious when you arrive on the scene and remains that way throughout transport) is more indicative of a severe traumatic brain injury with continuous loss of consciousness rather than the characteristic pattern of an epidural hematoma. Choice D (Sudden, severe headache) is more commonly associated with subarachnoid hemorrhage or traumatic brain injury but not specifically with epidural hematoma.