A nurse counsels a patient diagnosed with body dysmorphic disorder. Which nursing diagnosis would be a priority for the plan of care?

Correct Answer: B

Rationale: The correct answer is B: Risk for suicide. This is the priority nursing diagnosis as patients with body dysmorphic disorder have an increased risk of suicidal ideation and behaviors. Addressing this risk is crucial for patient safety. A: Anxiety is a common symptom of body dysmorphic disorder but may not be the priority if the patient is at risk for suicide. C: Disturbed body image is a characteristic of body dysmorphic disorder, but addressing the risk of suicide takes precedence. D: Ineffective role performance may be a concern, but it is not as urgent as addressing the risk for suicide in this case.

Correct Answer: A

Rationale: In this scenario, option A, which instructs the nursing assistant to position the patient sitting up in bed before feeding her, is the correct answer. This is because positioning the patient in an upright position helps prevent aspiration, a common risk for stroke patients with swallowing difficulties. By sitting the patient up, gravity assists in the safe passage of food down the esophagus. Option B, checking the patient's gag and swallowing reflexes, is important but should have been done by the healthcare provider or nurse before the feeding task. Nursing assistants should not independently assess these reflexes. Option C is incorrect as it promotes rushing through the feeding process, which can increase the risk of aspiration and compromise the patient's safety and dignity. Option D is also incorrect because suctioning between bites of food is not a standard practice and should only be done if there is a specific medical indication for it. Educationally, this question highlights the importance of proper positioning during feeding for stroke patients to prevent complications like aspiration pneumonia. It emphasizes the role of nursing assistants in following established protocols for patient safety and the importance of understanding the rationale behind each task in patient care.

Correct Answer: A

Rationale: In the management of epilepsy, the primary factor in determining the choice of anticonvulsant medication is seizure classification (Option A). Seizure classification is crucial as different types of seizures respond better to specific anticonvulsants. For example, absence seizures are typically treated with different medications than focal seizures. The other options are not the primary factor in choosing an anticonvulsant medication. The size of the dosage (Option B) is important for determining the therapeutic range and ensuring efficacy but is not the primary factor in initial selection. The age of the patient (Option C) is a consideration due to potential side effects and dosing adjustments, but it is not the primary factor in choosing the medication. Side effects produced (Option D) are important to monitor and manage, but they are not the primary factor in the initial selection of the anticonvulsant. In an educational context, understanding the rationale behind choosing anticonvulsant medications based on seizure classification is essential for healthcare professionals involved in the care of patients with epilepsy. It ensures that the most appropriate treatment is selected, leading to better seizure control and improved quality of life for patients. Educating healthcare providers on this principle enhances their clinical decision-making skills and ultimately improves patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) observing for myasthenic crisis. When a patient's medication is being adjusted, especially in the case of Susan who may be on medications affecting neuromuscular transmission like those for myasthenia gravis, it is crucial to monitor for potential complications such as myasthenic crisis. This is a life-threatening condition characterized by severe muscle weakness that can lead to respiratory failure. Prioritizing the observation for signs and symptoms of myasthenic crisis ensures prompt recognition and intervention if it occurs, which is essential for patient safety and well-being. Option A) developing a therapeutic relationship, while important for overall care, is not the priority when a patient's medication is being adjusted and a potential crisis needs to be monitored for. Option C) initiating a teaching plan and Option D) instructing her family about medications are also important aspects of care but do not take precedence over the immediate safety concern of monitoring for myasthenic crisis. In an educational context, understanding the prioritization of care based on the patient's condition and potential complications is vital for healthcare providers to ensure effective and safe patient management. This question highlights the importance of critical thinking and clinical decision-making in prioritizing nursing interventions during medication adjustments and potential crisis situations in neurological system assessments.

Correct Answer: A

Rationale: In this question, the correct answer is A) hyperthermia. During spinal shock, which is a temporary loss of reflexes below the level of a spinal cord injury, the body's ability to regulate temperature, including perspiration, is disrupted. As a result, the patient is unable to sweat below the level of the injury, leading to a decreased ability to cool down the body. This can result in hyperthermia, an elevated body temperature. Option B) overhydration is incorrect because the inability to perspire does not lead to increased hydration. Option C) hypertension is incorrect as there is no direct link between the inability to perspire and increased blood pressure. Option D) autonomic dysreflexia is also incorrect as this condition occurs after spinal shock and is characterized by a sudden onset of excessively high blood pressure. In an educational context, understanding the physiological responses and complications of spinal cord injuries is crucial for healthcare providers, especially those involved in caring for patients with such injuries. Recognizing the effects of spinal shock on temperature regulation can help healthcare professionals anticipate and prevent complications such as hyperthermia in these patients. This knowledge is essential for providing safe and effective care to individuals with spinal cord injuries.