A 30-year-old woman tells the nurse that she has been very unsteady and has had difficulty in maintaining her balance. Which area of the brain that is related to these findings would concern the nurse?

Correct Answer: C

Rationale: The correct answer is C: Cerebellum. The cerebellum is responsible for coordinating voluntary movements, balance, and posture. Damage to the cerebellum can result in symptoms like unsteadiness and difficulty maintaining balance. The thalamus (A) is involved in relaying sensory and motor signals but is not directly related to balance. The brainstem (B) plays a role in basic life functions like breathing and heart rate, not balance. The extrapyramidal tract (D) is involved in regulating motor activities but is not primarily responsible for balance control.

Correct Answer: D

Rationale: The correct answer is D because the patient diagnosed with dissociative amnesia typically struggles with memory loss. By describing previously forgotten experiences, the patient demonstrates progress in accessing and processing their memories. This indicates improvement in their ability to execute complex mental processes. A - Functioning independently is too broad and does not directly address the cognitive aspect of dissociative amnesia. B - Verbalizing feelings of safety focuses more on emotional regulation rather than cognitive abilities. C - Regularly attending diversional activities may be beneficial for overall well-being but does not specifically target the core issue of memory impairment in dissociative amnesia.

Correct Answer: B

Rationale: In this scenario, the correct action to take first is option B) Check the Foley tubing for kinks or obstruction. The patient's presentation with a sudden severe headache, along with increased blood pressure, decreased heart rate, diaphoresis, and flushing, indicates autonomic dysreflexia, a medical emergency commonly seen in individuals with spinal cord injuries. Autonomic dysreflexia is characterized by a sudden onset of excessively high blood pressure triggered by a noxious stimulus below the level of injury, such as a blocked urinary catheter (Foley tubing). Checking the Foley tubing for kinks or obstruction is crucial because addressing this issue can help alleviate the noxious stimulus triggering autonomic dysreflexia and prevent further complications such as seizures, stroke, or even death. The other options are not the most appropriate actions to take in this situation: A) Administering acetaminophen may help with the headache but does not address the underlying cause of autonomic dysreflexia. C) Adjusting the room temperature is not a priority when dealing with a medical emergency like autonomic dysreflexia. D) Notifying the physician is important but should come after addressing the immediate issue of the blocked Foley tubing to stabilize the patient's condition. This case underscores the importance of prompt recognition and intervention in managing autonomic dysreflexia in patients with spinal cord injuries, highlighting the critical role of nursing assessment and quick decision-making in ensuring patient safety and well-being.

Correct Answer: A

Rationale: The correct answer is A) The student enters the room without putting on a mask and gown. This action requires immediate intervention because patients with meningococcal meningitis are highly contagious, and strict infection control measures must be followed to prevent the spread of the disease. Failure to use personal protective equipment (PPE) like masks and gowns puts the patient, staff, and visitors at risk of contracting the infection. Option B is incorrect because instructing the family about visitation restrictions is within the scope of caring for a patient with an infectious disease to prevent further spread. Option C is incorrect as providing a warm blanket to a patient feeling cold is a comfort measure that does not pose a risk to the patient or others. Option D is incorrect as checking the patient's pupil response is a standard neurological assessment and does not pose an immediate risk in this scenario. In an educational context, it is crucial to emphasize the importance of following infection control protocols, especially in high-risk settings like the ICU. Students must understand the rationale behind these measures to prioritize patient safety and prevent healthcare-associated infections. Reinforcing the use of PPE and proper isolation techniques is essential for student nurses to provide safe and effective care in such environments.

Correct Answer: A

Rationale: In this case, the correct answer is option A) decreasing level of consciousness. This is an early indication of increasing intracranial pressure (ICP) because as pressure within the skull rises, it can impede blood flow to the brain, leading to altered mental status. This change in consciousness is a crucial sign that requires immediate attention as it indicates potential brain dysfunction. Option B) increasing systolic blood pressure is not typically an early sign of increasing ICP. While the body may try to compensate for the rising pressure by increasing blood pressure, this is not an early indicator and may occur later in the process. Option C) slowing of respirations is more commonly associated with brain stem dysfunction due to severe increases in ICP, rather than being an early sign. It is a late and serious sign of impending herniation. Option D) decreasing pulse rate is not typically an early indicator of increasing ICP. In fact, the pulse rate may be variable or initially increase in response to stress before decreasing in later stages of increased ICP. Educationally, understanding these early signs of increasing ICP is crucial for healthcare professionals, especially those working in neurology, critical care, or emergency settings. Recognizing these signs promptly can lead to timely interventions that can prevent further neurological damage and improve patient outcomes. This knowledge is essential for providing safe and effective care to patients at risk for intracranial hypertension.