A 49-year-old patient is diagnosed with Huntington's disease. He thought he saw symptoms of the disease in his 15-year-old son. What is the best response?

Correct Answer: B

Rationale: The correct answer is B) Huntington's disease is genetically transmitted. This response is the best choice because Huntington's disease is an autosomal dominant genetic disorder. It is important for the patient to understand that the disease can be passed down through generations due to a mutation in the HTT gene. Option A is incorrect because stating that the son probably has early symptoms without proper genetic testing or evaluation can cause unnecessary distress to the family. It is essential to approach such situations with sensitivity and accuracy to avoid misinformation. In an educational context, understanding the genetic basis of neurological disorders like Huntington's disease is crucial for healthcare professionals. By recognizing the inheritance pattern and the implications for family members, nurses and other healthcare providers can offer appropriate support, genetic counseling, and resources to affected individuals and their families. This knowledge helps in providing comprehensive care and addressing the emotional and psychological aspects of genetic conditions.

Correct Answer: A

Rationale: Controlling body temperature in a client with a brain infection is crucial to prevent complications. The correct answer is A) Administering prescribed antipyretics. Antipyretics help reduce fever by acting on the hypothalamus to lower the body's temperature set point. This is important because high temperatures can worsen brain swelling and increase metabolic demands. Reducing body hydration (Option B) is incorrect because dehydration can lead to further complications in a client with a brain infection. Proper hydration is essential for maintaining cerebral perfusion and overall physiological functions. Applying ice packs (Option C) is not recommended as it can cause vasoconstriction and potentially worsen cerebral blood flow, leading to adverse outcomes in a client with a brain infection. Keeping the room temperature warm (Option D) is also not ideal because it can exacerbate fever in a client with a brain infection. Maintaining a cooler room temperature can help prevent further elevation of body temperature. In an educational context, understanding the rationale behind using antipyretics in controlling body temperature in clients with brain infections is essential for nursing practice. Nurses need to be aware of the implications of fever on neurological conditions and the appropriate interventions to manage it effectively. This knowledge ensures optimal care and positive outcomes for clients with neurological issues.

Correct Answer: A

Rationale: The correct answer is A) An IV line is inserted to provide access to a vein. This intervention is crucial because shock can occur as a complication of spinal cord injury due to neurogenic shock, which can lead to inadequate perfusion and oxygenation of tissues. Establishing IV access allows for the administration of fluids and medications to stabilize the client's condition and prevent further complications. Option B) Head and back immobilization with a cervical collar and back support is not directly related to managing shock in a client with spinal cord injury. While immobilization is important for spinal cord injury, it does not address the immediate need to manage shock. Option C) Traction with weights and pulleys is a treatment for spinal cord injuries to stabilize and align the spine, but it is not a precautionary measure for managing shock. Option D) The use of a turning frame is not indicated for managing shock in a client with spinal cord injury. Turning frames are typically used for repositioning and preventing pressure ulcers, not for addressing shock. In an educational context, understanding the rationale behind each nursing intervention is crucial for providing safe and effective care to clients with spinal cord injuries. Nurses must prioritize interventions that address the client's immediate physiological needs, such as managing shock, to ensure positive outcomes for their patients.

Correct Answer: D

Rationale: The correct answer to the question is option D, which states, "Be sure to take fluids frequently." This is the most appropriate advice for a client with a neurological deficit related to nutrition and diet for several reasons. Neurological deficits can affect swallowing function, leading to an increased risk of dehydration and aspiration. Encouraging the client to take fluids frequently helps maintain hydration, aids in swallowing, and prevents complications such as aspiration pneumonia. Option A, eating two large meals instead of frequent small meals, is incorrect because it can overload the digestive system, especially for individuals with neurological deficits that may have difficulty with digestion and absorption. Consuming smaller, more frequent meals is generally recommended for better nutrient absorption and energy distribution throughout the day. Option B, consuming a diet low in fiber, is also incorrect. Fiber is essential for digestive health and regular bowel movements. A diet low in fiber can lead to constipation, which can be exacerbated in individuals with neurological deficits who may already have gastrointestinal issues. Option C, chewing foods quickly, is incorrect as well. Clients with neurological deficits may have difficulty with chewing and swallowing, which can increase the risk of choking and aspiration. Chewing food thoroughly and slowly is important to prevent these risks and aid in digestion. In an educational context, it is crucial for nurses to provide tailored nutrition and diet advice to clients with neurological deficits to promote optimal health and prevent complications. Understanding the specific needs and challenges faced by these individuals is essential in developing appropriate dietary recommendations that support their overall well-being. Encouraging frequent fluid intake is a simple yet effective strategy to address hydration and swallowing issues commonly seen in this population.

Correct Answer: C

Rationale: In managing a patient with delirium, it is essential to prioritize the identification and treatment of underlying causes whenever possible. This is the correct answer (Option C) because delirium is often a symptom of an underlying medical issue such as infection, medication side effects, or metabolic disturbances. By addressing the root cause, the delirium can be effectively managed or resolved. Option A, the use of restraints, is inappropriate as it can lead to physical and psychological harm, and should only be considered as a last resort for safety reasons. Option B, the use of short-acting benzodiazepines, can worsen delirium by exacerbating confusion and sedation. Option D, administering high doses of antipsychotic drugs, is not recommended as it can increase the risk of adverse effects in elderly patients and those with underlying neurological conditions. In an educational context, understanding the management of delirium is crucial for healthcare professionals, especially those preparing for exams like the NCLEX. By emphasizing the importance of identifying and addressing underlying causes, students can provide safe and effective care for patients experiencing delirium, promoting better outcomes and quality of life.