AACN Exam CCRN-Adult Topic 1 Question 1 Discussion

Actual exam question for AACN's CCRN-Adult exam

Question #: 1
Topic #: 1

Assessment of a patient with a head injury reveals increased muscle tone and contractured positioning of the upper extremities. A nurse should

Ause wrist restraints to maintain upper extremity extension.

Bobtain an order for a muscle relaxer.

Crecognize that contractures are an expected response after a head injury.

Dconsult a physical therapist regarding appropriate positioning.

Show Suggested Answer

Suggested Answer: D

In patients with head injuries, increased muscle tone and contractured positioning (such as decorticate or decerebrate posturing) are signs of significant neurological impairment. It is essential to manage these symptoms to prevent further complications. Consulting a physical therapist is the best course of action to ensure appropriate positioning, prevent contractures, and manage spasticity effectively. Reference: = CCRN Exam Handbook and AACN's Certification Review Course materials.

by Whitney at Mar 07, 2025, 10:40 PM

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