A patient diagnosed with depersonalization disorder tells the nurse, It's starting again. I feel as though I'm going to float away. The nurse should help the patient by:

Correct Answer: D

Rationale: The correct answer is D: helping the patient focus on the here and now. This is appropriate for depersonalization disorder as it helps the patient ground themselves in reality and reduce dissociative symptoms. Encouraging meditation (A) may exacerbate dissociation by further disconnecting the patient from reality. Administering an anxiolytic medication (B) may provide temporary relief but does not address the underlying issue. Helping the patient visualize a pleasant scene (C) may be soothing but may not be effective in addressing the dissociative symptoms.

Correct Answer: C

Rationale: The correct answer is C) Alteplase dissolves clots and may cause more bleeding into your wife's brain. In the context of an acute hemorrhagic stroke, where bleeding in the brain has already occurred, administering a clot-busting medication like alteplase can exacerbate the bleeding, leading to further damage and complications. It is crucial to differentiate between ischemic strokes (where a clot blocks blood flow) and hemorrhagic strokes (where a blood vessel ruptures), as the management approaches are different. Option A is incorrect because it does not address the specific risk of using alteplase in a hemorrhagic stroke. Option B is incorrect as alteplase is not primarily used for acute heart attacks but for ischemic strokes. Option D is incorrect as a history of gallbladder surgery is not a contraindication for alteplase use in stroke management. Educationally, understanding the rationale behind the use or avoidance of specific treatments in different types of strokes is vital for nursing practice, especially in emergency situations like acute strokes. It highlights the importance of accurate assessment, diagnosis, and treatment selection based on the underlying pathology to optimize patient outcomes and prevent harm.

Correct Answer: A

Rationale: The correct answer is A) lie down in a safe place. When a person experiences an aura before a seizure, it serves as a warning sign that a seizure is imminent. Instructing the person to lie down in a safe place helps prevent injury during the seizure. Option B) take additional anticonvulsant medication is incorrect because taking medication during a seizure is not safe or effective. Anticonvulsant medications are prescribed to prevent seizures, not to be taken as needed during a seizure. Option C) call an ambulance is not necessary for every seizure, especially if the person is aware of their seizure pattern and can manage it safely. Option D) exercise vigorously is unsafe during a seizure and can increase the risk of injury. It is important to promote a safe environment and positioning during a seizure to prevent harm. In an educational context, it is crucial for nurses to understand seizure management to provide safe and effective care to patients. Teaching individuals with epilepsy about seizure precautions and appropriate responses helps empower them to manage their condition effectively. Nurses play a key role in educating patients and caregivers on seizure first aid, including the importance of lying down in a safe place during an aura to prevent injury.

Correct Answer: A

Rationale: The correct answer is A) Atropine sulfate. In the context of an edrophonium (Tensilon) test, which is used to diagnose myasthenia gravis, atropine sulfate must be available as an antidote. Edrophonium is a cholinesterase inhibitor that temporarily increases acetylcholine levels at the neuromuscular junction, potentially causing cholinergic crisis characterized by excessive muscarinic stimulation. Atropine sulfate, an anticholinergic agent, is used to counteract the muscarinic effects by blocking the action of acetylcholine at muscarinic receptors, effectively reversing the cholinergic crisis symptoms. The other options are incorrect because: - B) Diazepam (Valium) is a benzodiazepine used for its anxiolytic and anticonvulsant properties, not for reversing cholinergic crisis. - C) Ephedrine is a sympathomimetic amine that acts on adrenergic receptors, not muscarinic receptors like atropine sulfate. - D) Corticosteroids are anti-inflammatory agents that are not indicated for acute cholinergic crisis management. Understanding the appropriate antidotes and interventions for potential complications during diagnostic tests is crucial for nursing practice. Knowing the specific antidote needed for cholinergic crisis in the context of an edrophonium test is essential to ensure prompt and effective management of adverse reactions, thereby improving patient safety and outcomes.

Correct Answer: B

Rationale: The correct answer is B) Muscle spasms are beginning to occur. Joe's leg movement of pulling away during the bath indicates the onset of muscle spasms, which is a common neurological response post-injury. This can be attributed to the hyperexcitability of nerves in the injured area, leading to involuntary muscle contractions. It is crucial for the nurse to recognize this sign as it may indicate the need for interventions to manage the muscle spasms and prevent further complications such as contractures. Option A) He is embarrassed about having to be bathed is incorrect because the behavior described is more indicative of a physiological response rather than an emotional one. Option C) Paralysis is diminishing due to reduction in edema is incorrect because a reduction in paralysis due to decreased edema would not manifest as muscle spasms but rather as improved voluntary muscle movement. Option D) He is adjusting negatively to his disability is incorrect because the behavior described is not a result of psychological adjustment but rather a physiological response related to the neurological injury. In an educational context, understanding the significance of changes in muscle tone and movement post-neurological injury is essential for nurses caring for patients with such conditions. Recognizing early signs of muscle spasms can help in implementing appropriate interventions to prevent complications and promote optimal recovery.