A patient with a spinal cord injury (SCI) complains about a severe throbbing headache that suddenly started a short time ago. Assessment of the patient reveals increased blood pressure (168/94) and decreased heart rate (48/minute), diaphoreses, and flushing of the face and neck. What action should you take first?

Correct Answer: B

Rationale: In this scenario, the correct action to take first is option B) Check the Foley tubing for kinks or obstruction. The patient's presentation with a sudden severe headache, along with increased blood pressure, decreased heart rate, diaphoresis, and flushing, indicates autonomic dysreflexia, a medical emergency commonly seen in individuals with spinal cord injuries. Autonomic dysreflexia is characterized by a sudden onset of excessively high blood pressure triggered by a noxious stimulus below the level of injury, such as a blocked urinary catheter (Foley tubing). Checking the Foley tubing for kinks or obstruction is crucial because addressing this issue can help alleviate the noxious stimulus triggering autonomic dysreflexia and prevent further complications such as seizures, stroke, or even death. The other options are not the most appropriate actions to take in this situation: A) Administering acetaminophen may help with the headache but does not address the underlying cause of autonomic dysreflexia. C) Adjusting the room temperature is not a priority when dealing with a medical emergency like autonomic dysreflexia. D) Notifying the physician is important but should come after addressing the immediate issue of the blocked Foley tubing to stabilize the patient's condition. This case underscores the importance of prompt recognition and intervention in managing autonomic dysreflexia in patients with spinal cord injuries, highlighting the critical role of nursing assessment and quick decision-making in ensuring patient safety and well-being.

Correct Answer: A

Rationale: In this case, the correct answer is option A) decreasing level of consciousness. This is an early indication of increasing intracranial pressure (ICP) because as pressure within the skull rises, it can impede blood flow to the brain, leading to altered mental status. This change in consciousness is a crucial sign that requires immediate attention as it indicates potential brain dysfunction. Option B) increasing systolic blood pressure is not typically an early sign of increasing ICP. While the body may try to compensate for the rising pressure by increasing blood pressure, this is not an early indicator and may occur later in the process. Option C) slowing of respirations is more commonly associated with brain stem dysfunction due to severe increases in ICP, rather than being an early sign. It is a late and serious sign of impending herniation. Option D) decreasing pulse rate is not typically an early indicator of increasing ICP. In fact, the pulse rate may be variable or initially increase in response to stress before decreasing in later stages of increased ICP. Educationally, understanding these early signs of increasing ICP is crucial for healthcare professionals, especially those working in neurology, critical care, or emergency settings. Recognizing these signs promptly can lead to timely interventions that can prevent further neurological damage and improve patient outcomes. This knowledge is essential for providing safe and effective care to patients at risk for intracranial hypertension.

Correct Answer: B

Rationale: The correct answer is B) Explaining the need for regular daily activity, rest, and relaxation would be most helpful in assisting Mrs. Brown to live with her multiple sclerosis. This is because maintaining a balance between activity and rest is crucial in managing symptoms and preventing exacerbations in multiple sclerosis. Regular physical activity can help improve strength, coordination, and overall well-being, while adequate rest and relaxation can help manage fatigue and stress, which are common in multiple sclerosis. Option A) Teaching her about specific diet restrictions may be important for overall health but is not the most crucial aspect in managing multiple sclerosis. Diet can play a role in managing symptoms, but it is not the primary focus. Option C) Encouraging regular appointments with a psychotherapist may be beneficial for emotional support and coping strategies, but it is not the most essential aspect in managing the physical symptoms of multiple sclerosis. Option D) Explaining that complete recovery can be expected is incorrect because multiple sclerosis is a chronic condition with unpredictable courses. Managing expectations and focusing on symptom management and quality of life are more realistic approaches in dealing with the disease. In an educational context, it is important to emphasize to students that a holistic approach to managing chronic conditions like multiple sclerosis is crucial. Understanding the importance of physical activity, rest, and stress management can help patients lead a better quality of life despite their diagnosis. Educating patients on self-care strategies empowers them to take an active role in managing their health and well-being.

Correct Answer: D

Rationale: The correct answer is D) will decrease the tendency for constipation. Encouraging a paraplegic patient to drink plenty of fluids is essential to prevent constipation, a common issue in individuals with limited mobility. Adequate fluid intake helps soften stool, making it easier to pass and reducing the risk of constipation, which can be exacerbated by factors such as reduced activity and certain medications. Option A) replaces fluid lost during periods of increased perspiration is incorrect in this context because paraplegic patients may not experience increased perspiration due to their limited mobility and lack of sensation below the level of injury. Option B) decreases renal calculi formation is incorrect because while adequate fluid intake can help prevent kidney stones, the primary reason for encouraging fluid intake in a paraplegic patient is to address constipation. Option C) tends to decrease the possibility of spinal shock is incorrect because fluid intake does not directly impact the occurrence of spinal shock. Spinal shock is a physiological response to spinal cord injury characterized by a temporary loss of function, and fluid intake does not specifically prevent or treat this condition. In an educational context, it is crucial for healthcare providers to understand the importance of individualized care for patients with neurological conditions like paraplegia. Ensuring proper hydration and addressing issues like constipation can significantly improve the patient's quality of life and prevent complications. Educating nurses and other healthcare professionals about the specific needs of patients with spinal cord injuries is essential for providing optimal care and promoting patient well-being.

Correct Answer: B

Rationale: In assessing Bob for radial nerve injury, the correct indication would be "B) Inability to extend the wrist." This is because the radial nerve innervates the muscles responsible for wrist extension, such as the extensor carpi radialis longus and brevis. Therefore, damage to the radial nerve would result in the inability to perform this action. Option A, "Pain at the fracture site," is not indicative of radial nerve injury specifically. Pain at the fracture site may be present in any type of injury involving a fracture. Option C, "Inability to flex the elbow," is more commonly associated with musculocutaneous nerve injury, as this nerve innervates the muscles responsible for elbow flexion. Option D, "Paralysis of the hand and forearm," is more characteristic of a more extensive nerve injury, such as a brachial plexus injury, rather than isolated radial nerve damage. Understanding the specific signs and symptoms associated with different nerve injuries is crucial in clinical assessment. This knowledge helps healthcare providers accurately diagnose and manage patients with neurological deficits, leading to appropriate treatment interventions and better patient outcomes.