A patient says, I feel detached and weird all the time, like I'm looking at life through a cloudy window. Everything seems unreal. These feelings really interfere with my work and study. Which term should the nurse use to document this complaint?

Correct Answer: A

Rationale: Correct Answer: A. Depersonalization Rationale: 1. Depersonalization involves feeling detached from oneself or reality, as described by the patient. 2. The patient's description of feeling like they are looking through a cloudy window aligns with depersonalization symptoms. 3. Interference with work and study suggests significant distress, a common feature of depersonalization disorder. Summary of other choices: B. Hypochondriasis: Involves excessive worry about having a serious illness, which is not indicated in the patient's complaint. C. Dissociation: While depersonalization is a type of dissociative symptom, it specifically refers to feeling detached and unreal, not necessarily a broader dissociative disorder. D. Malingering: Involves feigning or exaggerating symptoms for secondary gain, which is not evident in the patient's genuine distress and impairment.

Correct Answer: B

Rationale: In this scenario, the correct patient to assess first is option B, the 45-year-old scheduled for a craniotomy in 30 minutes who needs preoperative teaching. This patient takes priority due to the impending surgical procedure, requiring immediate attention to ensure understanding of the process, potential risks, and postoperative care. Preoperative teaching is crucial for informed consent, anxiety reduction, and optimal surgical outcomes. Option A, the 23-year-old with a migraine and severe nausea, while in discomfort, does not have an urgent procedure or immediate risk that would warrant assessment before the patient scheduled for surgery. Option C, the 59-year-old with Parkinson's disease needing a swallowing assessment, is important but can be done after addressing the imminent surgical case. Option D, the 63-year-old with multiple sclerosis and a fever, presents with concerning symptoms but does not have an urgent procedure scheduled like the patient in option B. The fever and flank pain require assessment and intervention but can be addressed after attending to the patient needing preoperative teaching. Educationally, understanding prioritization in nursing care is vital. This scenario highlights the importance of triaging patients based on acuity, urgency, and potential risks. It emphasizes the significance of time management, critical thinking, and decision-making in providing safe and effective patient care. Prioritizing care ensures that the most critical needs are addressed promptly, leading to better outcomes for patients.

Correct Answer: A

Rationale: In the scenario presented, Mr. Smith is experiencing signs of increased intracranial pressure, a serious condition that requires immediate intervention. The correct medication likely to be ordered for Mr. Smith in this situation is A) Mannitol. Mannitol is an osmotic diuretic that works by reducing cerebral edema and intracranial pressure. It does this by drawing water out of brain tissue and into the bloodstream, ultimately decreasing the pressure inside the skull. Now, let's discuss why the other options are incorrect: - B) Insulin: Insulin is not used to treat increased intracranial pressure. Its primary role is to regulate blood sugar levels in the body. - C) Morphine sulfate: Morphine sulfate is an opioid analgesic used for pain relief and is not indicated for managing increased intracranial pressure. - D) Penicillin: Penicillin is an antibiotic used to treat bacterial infections and has no direct impact on reducing intracranial pressure. Educational context: Understanding the appropriate medications for managing increased intracranial pressure is crucial for healthcare professionals, especially those working in critical care settings. Knowledge of medications like Mannitol and their mechanisms of action is vital in providing timely and effective care to patients with neurological emergencies.

Correct Answer: C

Rationale: Rationale: The correct answer is C) assisting with activities of daily living. In Parkinson's disease, a neurodegenerative disorder affecting movement, muscle control, and balance, patients often experience a range of motor and non-motor symptoms. One of the hallmark features of Parkinson's is the progressive loss of ability to perform activities of daily living independently due to muscle rigidity, tremors, and bradykinesia. Therefore, assisting with activities of daily living such as grooming, dressing, eating, and mobility becomes a major nursing need to maintain Mrs. Moore's quality of life. Option A) monitoring for seizures is incorrect as seizures are not a typical manifestation of Parkinson's disease. Option B) decreasing pain tolerance is also incorrect as Parkinson's does not directly affect pain tolerance. Option D) preventing diarrhea is not a major nursing need in Parkinson's disease unless related to medication side effects, but it is not a primary concern compared to assisting with activities of daily living. In an educational context, understanding the specific nursing needs of patients with neurological conditions like Parkinson's disease is crucial for providing effective and holistic care. Nurses must be skilled in assessing, planning, and implementing care strategies that focus on maintaining patient independence and quality of life while managing the progressive symptoms of the disease. By recognizing and addressing these major nursing needs, nurses can enhance the overall well-being and functional status of patients like Mrs. Moore living with Parkinson's disease.

Correct Answer: A

Rationale: In the acute phase following a cerebrovascular accident (CVA), also known as a stroke, patients are at risk of developing pressure ulcers due to immobility and altered sensory perception. The correct answer, A) high degree of muscle spasticity, is the exception because muscle spasticity actually helps in preventing pressure ulcers by providing intermittent pressure relief. Option B) accompanying sensory loss can lead to decreased awareness of discomfort or pain, increasing the risk of pressure ulcers. Option C) interference with altered autonomic reflexes can affect blood flow and skin integrity, contributing to pressure ulcer development. Option D) diminished muscle use results in prolonged pressure on bony prominences, further increasing the risk of pressure ulcers. From an educational perspective, understanding the factors contributing to pressure ulcer development in stroke patients is crucial for nursing and healthcare professionals. This knowledge informs preventive strategies such as repositioning, skin assessments, and pressure redistribution devices to mitigate the risk of pressure ulcers in this vulnerable population.