A patient is admitted to the emergency department with a spinal cord injury at the level of T2. Which finding is of most concern to the nurse?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Heart rate of 42 bpm. When a patient sustains a spinal cord injury at the level of T2, it can lead to autonomic dysreflexia, a potentially life-threatening condition. A sudden increase in blood pressure can stimulate the vagus nerve, causing bradycardia (slow heart rate). This response is a critical indication of autonomic dysreflexia. Option A) SpO2 of 92% is suboptimal but does not pose an immediate threat compared to a bradycardia. Option C) Blood pressure of 88/60 mm Hg is low but can be a normal response to the injury and not as concerning as the bradycardia. Option D) Loss of motor and sensory function in arms and legs, while significant, is an expected outcome of a spinal cord injury at T2 and is not as acutely dangerous as bradycardia in this context. Educationally, understanding the specific complications of spinal cord injuries, such as autonomic dysreflexia, is crucial for nurses caring for these patients. Recognizing the signs and symptoms of autonomic dysreflexia promptly is vital to prevent severe complications and provide timely interventions. This question highlights the importance of prioritizing assessments based on the potential for immediate harm in patients with spinal cord injuries.

Correct Answer: B

Rationale: In the case of a patient diagnosed with torticollis, the correct action for the nurse to provide is option B) Exercises to increase the strength of the muscles. Torticollis, also known as wry neck, is a condition characterized by a twisted or tilted neck due to involuntary muscle contractions. By engaging in specific exercises, the patient can help improve muscle strength and flexibility, which can alleviate the symptoms of torticollis over time. Option A) An immobilizer to hold the bones in place is incorrect because torticollis is primarily a muscular issue rather than a problem with bones that need immobilization. Using an immobilizer would not address the underlying cause of the condition. Option C) A pillow to use to support the knees while sleeping and Option D) Enough pillows to support the patient's head comfortably are also incorrect as they do not directly target the muscles of the neck that are affected in torticollis. While supportive pillows may provide some comfort, they do not address the need for muscle strengthening to improve the condition. From an educational standpoint, understanding the rationale behind the correct answer not only reinforces knowledge of torticollis but also highlights the importance of non-pharmacological interventions such as exercises in managing musculoskeletal conditions. Nurses play a vital role in educating patients on self-care strategies like exercises, empowering them to actively participate in their treatment and recovery process.

Correct Answer: D

Rationale: In the emergency department, the priority intervention for a patient with a stroke is option D, which is the maintenance of respiratory function with a patent airway and oxygen administration. This is crucial because adequate oxygenation is essential for brain function and to prevent further damage in a patient experiencing a stroke. The other options are not the priority interventions for a stroke patient in the emergency department. Option A, intravenous fluid replacement, may be necessary but is not the immediate priority in a stroke situation. Option B, administration of osmotic diuretics, is not the first-line intervention and is typically used later in stroke management. Option C, initiation of hypothermia, is not a standard intervention for stroke in the acute setting. Educationally, it is important for healthcare providers to understand the critical nature of maintaining respiratory function in stroke patients to optimize oxygen delivery to the brain. This knowledge is essential for providing effective care and improving patient outcomes in stroke management. It is vital for nurses and other healthcare professionals to prioritize interventions based on the immediate needs of the patient to ensure the best possible outcome.

Correct Answer: C

Rationale: The correct answer is C) Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety. This intervention is appropriate because it directly addresses the environmental factors that can contribute to exacerbating anxiety in a patient with a headache. A quiet and dimly lit environment can help reduce sensory stimuli, promoting relaxation and potentially alleviating the patient's anxiety. Option A) Help the patient to examine lifestyle patterns and precipitating factors is not the most appropriate intervention in this context as it focuses more on identifying contributing factors rather than addressing the immediate need to reduce anxiety. Option B) Administer medications as ordered to relieve pain and promote relaxation may be necessary for pain relief but does not directly address the anxiety related to lack of knowledge about the headache etiology and treatment. Educationally, it is important for nurses to understand the holistic approach to patient care, considering not only the physical symptoms but also the psychological and environmental factors that can impact a patient's well-being. Providing a calm and soothing environment is a non-invasive, patient-centered intervention that can help manage anxiety and promote comfort in patients experiencing headaches.

Correct Answer: C

Rationale: In this scenario, option C, "Weakness of one leg resulting in a limping walk," is the most indicative of Parkinson's disease. Parkinson's disease is a neurodegenerative disorder characterized by motor symptoms like bradykinesia, rigidity, tremors, and postural instability. The weakness in one leg leading to a limping walk can be a manifestation of bradykinesia and muscle rigidity commonly seen in Parkinson's patients. Option A, "Large embellished handwriting," is more suggestive of a condition called micrographia, where handwriting becomes smaller and more cramped in Parkinson's disease, not larger and embellished as described in the option. Option D, "Difficulty rising from a chair and beginning to walk," is a common symptom in Parkinson's disease due to bradykinesia and rigidity, but weakness in one leg resulting in a limping walk is more specific to Parkinson's and aligns better with the typical gait disturbances seen in this condition. Educationally, understanding the specific motor symptoms of Parkinson's disease is crucial for nurses to recognize the early signs and provide appropriate care and support to patients. Assessing gait abnormalities, like a limping walk due to leg weakness, can help in early detection and timely intervention in Parkinson's disease. This knowledge enhances the nurse's ability to collaborate with the healthcare team in managing Parkinson's patients effectively.