After a hospitalization for Syndrome of Inappropriate Antidiuretic Hormone (SIADH), a client develops pontine myelinolysis. Which intervention should the nurse implement first?

Correct Answer: A

Rationale: In this scenario, the correct intervention is option A) Reorient client to his room. Pontine myelinolysis is a serious neurological condition characterized by the destruction of the myelin sheath in the pons region of the brain. Symptoms include confusion, dysphagia, quadriplegia, and can be life-threatening. Reorienting the client to his room is the priority as confusion is a common symptom and the client may be disoriented due to the neurological damage. Option B) Place a patch on one eye is unrelated to the client's condition and would not address the neurological symptoms associated with pontine myelinolysis. Option C) Evaluate client's ability to swallow is important but not the most immediate concern in this situation. Option D) Perform range of motion exercises is not a priority when dealing with a neurological emergency like pontine myelinolysis. Educationally, understanding the priority interventions in neurological emergencies is crucial for nurses caring for pediatric patients with complex conditions. This question highlights the importance of quick thinking and prioritization in the face of a critical situation to provide optimal care and support to the patient.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) The xenograft is taken from nonhuman sources. Explanation: Xenografts are skin grafts taken from a different species, such as pig or cow, and used in burn patients to promote healing. Providing this information to a Jewish client is crucial for cultural sensitivity, as some Jewish individuals may have dietary restrictions or beliefs that impact their acceptance of treatments involving nonhuman sources. Why others are wrong: A) Grafting increases the risk for bacterial infections: While this is a potential risk associated with any type of grafting procedure, it is not specific to xenografts and is not the most pertinent information for preoperative education in this case. C) Grafts are later removed by a debriding procedure: This statement is inaccurate as xenografts are typically used as temporary coverings until the patient's own skin can be used for grafting, and they are not removed by debriding procedures. D) As the burn heals, the graft permanently attaches: This statement is incorrect as xenografts are temporary and eventually slough off as the patient's own skin regenerates underneath. Educational context: Understanding the source and nature of the graft is essential for the client's informed decision-making and compliance with the treatment plan. Providing culturally sensitive and accurate information ensures effective communication and fosters trust between the healthcare provider and the client.

Correct Answer: C

Rationale: In this scenario, the correct action for the nurse to implement is to measure the patient's pulse and blood pressure (Option C). This is crucial because the patient is experiencing symptoms of weakness and jitteriness, which could indicate hypoglycemia, a common complication in diabetes management. Checking the pulse and blood pressure can help assess the patient's hemodynamic status and provide valuable information about his overall condition. Option A (Checking his fingerstick glucose level) could also be important in this situation to confirm if the patient's symptoms are indeed related to hypoglycemia. However, measuring the pulse and blood pressure takes precedence as it provides immediate data on the patient's cardiovascular status, especially during a perioperative period. Options B (Assessing his skin temperature and moisture) and D (Documenting anxiety on the surgical checklist) are not the most appropriate actions to take in response to the patient's symptoms. While assessing skin temperature and moisture can provide some information about the patient's perfusion status, it may not directly address the immediate concern of weakness and jitteriness. Documenting anxiety, although important for holistic care, does not address the physiological symptoms the patient is experiencing and should not be the priority in this situation. From an educational perspective, this scenario highlights the importance of prioritizing nursing actions based on the patient's presenting symptoms and clinical context. Understanding the significance of assessing vital signs in a timely manner, especially in patients with comorbid conditions like diabetes, is crucial for providing safe and effective care. It also underscores the need for nurses to be adept at recognizing and managing potential complications in patients with chronic illnesses undergoing surgical procedures.

Correct Answer: D

Rationale: In this scenario, the most immediate action by the nurse should be prompted by the further decline in the level of consciousness (Option D). This is crucial because a worsening level of consciousness can indicate a deterioration in the client's condition, potentially leading to life-threatening complications. In pediatric patients, changes in mental status are critical indicators of systemic compromise and require immediate attention to prevent adverse outcomes. Option A, facial puffiness and periorbital edema, are common symptoms of hypothyroidism and may not require immediate action unless severe or accompanied by other concerning signs. Option B, a hematocrit of 30%, while low, may not be the most immediate concern compared to a declining level of consciousness. It could indicate anemia, which should be addressed but is not as urgent as a neurological deterioration. Option C, cold and dry skin, is also a symptom of hypothyroidism and may not warrant immediate action unless it is severe and contributing to the decline in the client's condition. In an educational context, understanding the prioritization of assessments and interventions based on the urgency of the client's condition is vital in pediatric nursing. This case highlights the importance of recognizing changes in consciousness as a red flag requiring immediate attention to prevent further deterioration and ensure optimal patient outcomes.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Pain. The probable etiology of the male client's difficulty sleeping is pain caused by Herpes zoster (shingles) lesions on his thorax. Pain associated with shingles can be intense and persistent, making it challenging for the client to find a comfortable position to sleep. This pain can disrupt the client's ability to fall asleep or stay asleep, leading to sleep disturbances. Option B) Nocturia, which is excessive urination at night, is not likely to be the cause of the client's sleep difficulty in this case. Option C) Dyspnea, which is difficulty breathing, and Option D) Frequent cough are also not relevant to the client's complaint of difficulty sleeping due to shingles-related pain. Educationally, understanding the impact of pain on sleep is crucial for nurses caring for clients with conditions like Herpes zoster. Nurses need to assess and manage pain effectively to promote quality sleep, which is essential for the client's overall well-being and recovery. By recognizing pain as a potential barrier to sleep, nurses can implement appropriate interventions to improve the client's comfort and rest.