A patient with Parkinson's disease has a nursing diagnosis of Impaired Physical Mobility related to neuromuscular impairment. You observe a nursing assistant performing all of these actions. For which action must you intervene?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) The NA performs the patient's complete bath and oral care. This is the action that requires intervention because it involves providing personal hygiene care, which is outside the scope of practice for a nursing assistant. Option A is correct as the NA assisting the patient to ambulate aligns with promoting physical mobility. Option B is incorrect as reminding the patient not to look at his feet is a helpful cue for individuals with Parkinson's disease to improve their gait. Option D is also acceptable as it encourages the patient's independence in feeding, which is important for maintaining physical function. Educationally, it is crucial to emphasize the scope of practice for nursing assistants and the importance of adhering to professional boundaries. Providing clear guidelines on what tasks they can and cannot perform ensures patient safety and quality care delivery. Additionally, understanding the specific needs of patients with Parkinson's disease is essential for tailoring care interventions to promote their functional independence and well-being.

Correct Answer: A

Rationale: In the management of epilepsy, the primary factor in determining the choice of anticonvulsant medication is seizure classification (Option A). Seizure classification is crucial as different types of seizures respond better to specific anticonvulsants. For example, absence seizures are typically treated with different medications than focal seizures. The other options are not the primary factor in choosing an anticonvulsant medication. The size of the dosage (Option B) is important for determining the therapeutic range and ensuring efficacy but is not the primary factor in initial selection. The age of the patient (Option C) is a consideration due to potential side effects and dosing adjustments, but it is not the primary factor in choosing the medication. Side effects produced (Option D) are important to monitor and manage, but they are not the primary factor in the initial selection of the anticonvulsant. In an educational context, understanding the rationale behind choosing anticonvulsant medications based on seizure classification is essential for healthcare professionals involved in the care of patients with epilepsy. It ensures that the most appropriate treatment is selected, leading to better seizure control and improved quality of life for patients. Educating healthcare providers on this principle enhances their clinical decision-making skills and ultimately improves patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) observing for myasthenic crisis. When a patient's medication is being adjusted, especially in the case of Susan who may be on medications affecting neuromuscular transmission like those for myasthenia gravis, it is crucial to monitor for potential complications such as myasthenic crisis. This is a life-threatening condition characterized by severe muscle weakness that can lead to respiratory failure. Prioritizing the observation for signs and symptoms of myasthenic crisis ensures prompt recognition and intervention if it occurs, which is essential for patient safety and well-being. Option A) developing a therapeutic relationship, while important for overall care, is not the priority when a patient's medication is being adjusted and a potential crisis needs to be monitored for. Option C) initiating a teaching plan and Option D) instructing her family about medications are also important aspects of care but do not take precedence over the immediate safety concern of monitoring for myasthenic crisis. In an educational context, understanding the prioritization of care based on the patient's condition and potential complications is vital for healthcare providers to ensure effective and safe patient management. This question highlights the importance of critical thinking and clinical decision-making in prioritizing nursing interventions during medication adjustments and potential crisis situations in neurological system assessments.

Correct Answer: A

Rationale: In this question, the correct answer is A) hyperthermia. During spinal shock, which is a temporary loss of reflexes below the level of a spinal cord injury, the body's ability to regulate temperature, including perspiration, is disrupted. As a result, the patient is unable to sweat below the level of the injury, leading to a decreased ability to cool down the body. This can result in hyperthermia, an elevated body temperature. Option B) overhydration is incorrect because the inability to perspire does not lead to increased hydration. Option C) hypertension is incorrect as there is no direct link between the inability to perspire and increased blood pressure. Option D) autonomic dysreflexia is also incorrect as this condition occurs after spinal shock and is characterized by a sudden onset of excessively high blood pressure. In an educational context, understanding the physiological responses and complications of spinal cord injuries is crucial for healthcare providers, especially those involved in caring for patients with such injuries. Recognizing the effects of spinal shock on temperature regulation can help healthcare professionals anticipate and prevent complications such as hyperthermia in these patients. This knowledge is essential for providing safe and effective care to individuals with spinal cord injuries.

Correct Answer: C

Rationale: In the case of Mr. Jones, the most appropriate position until doctor's orders are received is lying on his right side. This position is preferred as it helps reduce pressure on the vena cava, the large vein that returns blood to the heart. By lying on the right side, Mr. Jones can optimize blood flow and cardiac output, which is crucial for patients in compromised health states. Option A, lying flat on his back, may impede blood flow through the vena cava, leading to decreased cardiac output and potential complications. Option B, lying on his left side, can compress the vena cava, also hindering blood flow. Option D, lying on his abdomen, is not suitable as it can cause respiratory distress and compromise airway patency. In an educational context, understanding the rationale behind positioning patients is crucial for nursing and medical students. It ensures safe and effective patient care by promoting optimal physiological function and preventing complications. Clinical reasoning skills are honed through understanding the implications of different positions on patient outcomes.