A patient who has been admitted to the medical unit with new-onset angina also has a diagnosis of Alzheimer's disease. Her husband tells you that he rarely gets a good night's sleep because he needs to be sure she does not wander during the night. He insists on checking each of the medications you give her to be sure they are the same as the ones she takes at home. Based on this information, which nursing diagnosis is most appropriate for this patient?

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for this patient is B) Caregiver Role Strain related to continuous need for providing care. This diagnosis is correct because the husband's statement indicates that he is experiencing strain and stress due to the constant need to monitor and care for his wife, who has Alzheimer's disease and is at risk of wandering during the night. This situation places a significant burden on the caregiver and can lead to physical, emotional, and mental exhaustion. Option A) Decreased Cardiac Output related to poor myocardial contractility is incorrect because there is no direct evidence in the scenario to support this nursing diagnosis. The patient's angina and Alzheimer's disease are not linked to poor myocardial contractility. Option C) Risk for Falls related to patient wandering behavior during the night is incorrect because while the patient's wandering behavior does pose a risk for falls, the focus of the question is on the caregiver's well-being, not solely on the patient's safety. Option D) Ineffective Therapeutic Regimen Management related to poor patient memory is incorrect because the husband's actions do not suggest an issue with the patient's memory affecting her ability to manage her therapeutic regimen. Instead, the scenario highlights the caregiver's struggle in managing the care of a patient with Alzheimer's disease. In an educational context, understanding and identifying caregiver role strain is crucial in providing holistic care to patients with chronic conditions like Alzheimer's disease. Nurses need to assess not only the patient's well-being but also the caregiver's ability to cope with the demands of caregiving. By recognizing and addressing caregiver role strain, healthcare professionals can support both the patient and the caregiver in maintaining their health and well-being.

Correct Answer: C

Rationale: In the context of autonomic dysreflexia, it is crucial to choose the correct immediate action to prevent serious complications. The correct answer, C) assess for bowel and bladder distention, is the most important initial step when Mr. Jones develops an attack of autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition characterized by a sudden onset of excessively high blood pressure, triggered by a noxious stimulus below the level of a spinal cord injury. In this scenario, bowel or bladder distention is a common trigger. Assessing for bowel and bladder distention is crucial because addressing the underlying cause can help resolve the autonomic dysreflexia episode. Failure to address this issue promptly can lead to severe consequences such as stroke, seizure, or even death. Now, let's analyze why the other options are incorrect: A) Elevating the head of his bed: While elevating the head of the bed is a standard intervention for managing autonomic dysreflexia once the cause is identified, it is not the most immediate or crucial step in this scenario. B) Monitoring his blood pressure closely: While blood pressure monitoring is essential in managing autonomic dysreflexia, it is not the most critical initial action when an episode occurs. Identifying and addressing the triggering cause should take precedence. D) Encouraging him to ventilate his concerns: While addressing Mr. Jones' concerns is essential for his overall well-being, it is not the most critical action in the acute management of autonomic dysreflexia. Immediate assessment and intervention to address the triggering cause are paramount. In an educational context, understanding the pathophysiology, triggers, and management of autonomic dysreflexia is crucial for healthcare professionals working with patients with spinal cord injuries. By prioritizing the assessment of bowel and bladder distention in this scenario, healthcare providers can effectively manage autonomic dysreflexia episodes and prevent serious complications.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Restricting fluid intake for 12 hours after a myelogram procedure. This restriction is necessary to prevent the risk of developing a post-procedure headache known as a "spinal headache." When contrast dye is injected into the spinal canal during a myelogram, there is a risk of a leak of cerebrospinal fluid (CSF) from the puncture site, which can lead to a headache if the body's fluid levels are not properly maintained. By restricting fluid intake, the body can help replenish the lost CSF and reduce the likelihood of developing a headache. Option A) Watching him for a possible sensitivity reaction is incorrect because it is a standard procedure to monitor patients for any allergic reactions after a myelogram due to the contrast dye used. Option B) Elevating his head and thorax 15-30° for 8 hours is incorrect as this position is typically recommended post-myelogram to help reduce the risk of CSF leakage and subsequent headache. Option D) Administering aspirin for headache is incorrect because aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided post-myelogram as they can increase the risk of bleeding due to their blood-thinning effects. Educational Context: Understanding the post-procedure care and potential complications following a myelogram is crucial for healthcare professionals to ensure patient safety and optimal recovery. By knowing the rationale behind each aspect of care, professionals can provide informed and effective support to patients undergoing such procedures. It is essential to follow the specific guidelines and recommendations to prevent adverse outcomes and promote the best possible patient outcomes.

Correct Answer: C

Rationale: In a medical emergency situation like an accident, placing the patient in the correct position can be crucial for their well-being. In this scenario, the correct answer is C) Supine position with head in neutral position. Placing Joe in a supine position with his head in a neutral position helps maintain proper alignment of the spine and ensures adequate blood flow to the brain. This position also minimizes the risk of further injury, especially in cases where there may be suspected head, neck, or spinal trauma. Option A) The position in which he was found is not ideal as it may not be the safest or most stable position for Joe, and it could exacerbate any potential injuries he may have sustained. Option B) Lateral position with arms flexed is not recommended in this case as it is more suitable for patients who are unconscious and need to maintain an open airway. Joe's condition and injuries are not specified in the question to warrant this position. Option D) Supine position with head flexed is also incorrect as flexing the head can potentially worsen any spinal injuries Joe may have sustained during the accident. Educationally, understanding the importance of proper patient positioning in emergency situations is vital for healthcare providers, first responders, and even the general public. It can make a significant difference in patient outcomes and prevent further harm. Proper training and knowledge of basic first aid principles, including correct positioning, can save lives and minimize complications in critical situations.

Correct Answer: C

Rationale: The correct answer is C) immobilize the spine and reduce the fracture. When Crutchfield tongs are inserted into the scalp and traction is applied, the main goal is to stabilize and immobilize the cervical spine to reduce the risk of further injury or damage. This is crucial in cases of cervical spine fractures or instability. Option A is incorrect because while preventing head movement is a part of the purpose, the primary goal is to immobilize the spine, not specifically to reduce cerebral complications. Option B is incorrect as crutchfield tongs are not primarily used to limit body movement or reduce edema. Option D is incorrect as the tongs are not directly related to preventing autonomic dysreflexia. In an educational context, understanding the rationale behind using Crutchfield tongs is essential for healthcare professionals managing patients with cervical spine injuries. This knowledge ensures proper application of the device and contributes to optimal patient outcomes by preventing further spinal cord damage.