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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Tamesha

22 days ago

Hey, if the patient's arms are like pretzels, we should just get them a job in a circus. But in all seriousness, D is the way to go.

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Louis

23 days ago

Wrist restraints? Really? That's like trying to put a band-aid on a broken bone. Option D is the only sensible choice here.

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Glendora

24 days ago

C is an interesting option, but I don't think we should just accept contractures as 'expected'. We need to be proactive in addressing them.

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2 months ago

Option D seems the most appropriate. Consulting a physical therapist is crucial for proper positioning and preventing contractures.

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Donte

19 days ago

I think obtaining a muscle relaxer may not address the root cause of the issue, consulting a physical therapist is a better approach.

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Patti

20 days ago

Using wrist restraints may not be the best option, consulting a physical therapist is a better choice.

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Mollie

22 days ago

I agree, a physical therapist can help with positioning to prevent contractures.

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Alana

29 days ago

Option D seems the most appropriate. Consulting a physical therapist is crucial for proper positioning and preventing contractures.

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Zachary

2 months ago

I think we should consult a physical therapist.

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