Early in the care of the patient diagnosed with a right-sided brain stroke and disturbed visual sensory perception related to homonymous hemianopsia, what should the nurse do?

Correct Answer: B

Rationale: The correct answer is B) Approach the patient from the left side to encourage the patient to turn the head. When a patient has homonymous hemianopsia due to a right-sided brain stroke, they have decreased vision on the left side of both eyes. By approaching the patient from the left side, the nurse encourages the patient to turn their head to the left, helping them compensate for their visual deficit and see the nurse more clearly. Option A is incorrect because placing objects on the right side within the patient's field of vision would not help the patient compensate for their visual deficit. Option C is incorrect as placing objects on the patient's left side does not encourage the patient to address their visual deficit. Option D is incorrect because patching the affected eye would not address the patient's visual perception issue but rather hinder their ability to scan the environment effectively. In an educational context, understanding how to care for patients with neurological deficits is crucial for nurses. By recognizing the specific needs of patients with homonymous hemianopsia, nurses can provide appropriate care and support to help these patients adapt and function better in their environment.

Correct Answer: C

Rationale: In a patient experiencing a myasthenic crisis, which is a life-threatening condition characterized by severe muscle weakness, the nurse's first priority should be to ensure adequate respiratory function. This is because the muscles responsible for breathing are significantly weakened during a myasthenic crisis, putting the patient at high risk for respiratory failure. Option A: Mobility is important for overall patient health but is not the priority in a myasthenic crisis where respiratory compromise can lead to immediate life-threatening consequences. Option B: Nutrition is essential for overall well-being, but in a myasthenic crisis, ensuring adequate ventilation takes precedence over nutritional concerns. Option D: Verbal communication is important for patient assessment and emotional support, but it is not the priority when the patient's respiratory function is compromised. Educationally, this question highlights the critical nature of prioritizing care in a life-threatening situation. Understanding the pathophysiology of myasthenic crisis and recognizing the potential for respiratory failure underscores the importance of quick and accurate decision-making in nursing practice. It also emphasizes the need for nurses to prioritize interventions based on the patient's condition to ensure optimal outcomes.

Correct Answer: B

Rationale: In this scenario, the correct nursing intervention for the patient is option B: Establish and consistently follow a daily schedule with the patient. This intervention is appropriate because patients with neurological system issues often benefit from structure and routine, which can help promote a sense of familiarity, security, and predictability. A daily schedule can also assist in managing symptoms, promoting independence, and facilitating optimal functioning for the patient. Option A, posting clocks and calendars in the patient's environment, while it may be helpful for some patients, does not address the need for a structured daily routine that option B provides. Option C, monitoring the patient's activities to maintain a safe environment, is important but does not specifically address the need for a daily schedule. Option D, stimulating thought processes by asking the patient questions, may be beneficial for cognitive function but does not address the overarching need for a structured routine. In an educational context, understanding the rationale behind selecting the appropriate nursing intervention is crucial for nursing students preparing for the NCLEX exam. By choosing option B, students demonstrate their understanding of the importance of structure and routine in caring for patients with neurological system issues. This rationale emphasizes the holistic approach to patient care, considering not only the physical but also the psychological and emotional needs of the patient.

Correct Answer: C

Rationale: Compartment syndrome is a serious condition that can occur following a traumatic injury, such as a fractured tibia with soft tissue damage. The correct answer, option C, "Distal pain unrelieved by opioid analgesics," is indicative of developing compartment syndrome. This is because in compartment syndrome, there is increased pressure within a muscle compartment, leading to impaired blood flow and tissue damage, resulting in severe pain that is not relieved by pain medication due to the compromised blood flow. Option A, "Paralysis of the toes," is incorrect as paralysis is a late sign of compartment syndrome. Option B, "Absence of peripheral pulses," is also a late sign and indicates severe compromise of blood flow. Option D, "Skin over the injury site is blanched when the bandage is removed," is not typically associated with compartment syndrome but may indicate other issues like poor circulation or pressure-related skin damage. Educationally, understanding the signs and symptoms of compartment syndrome is crucial for nurses caring for patients with traumatic injuries. Recognizing early signs like unrelieved pain is essential for prompt intervention to prevent further tissue damage and potential limb loss. Nurses must be vigilant in assessing patients with injuries at risk for compartment syndrome to provide timely and appropriate care.

Correct Answer: B

Rationale: The correct answer is B) It should be treated with ordered analgesics. In this scenario, the patient is experiencing phantom limb pain, a common phenomenon where individuals feel pain in a limb that has been amputated. This pain can be intense and debilitating for some patients. Using analgesics can help manage this pain effectively, providing relief and improving the patient's comfort. Option A is incorrect because while swelling at the incision site can cause pain, in this case, the pain is likely due to the phenomenon of phantom limb pain rather than incision-related issues. Option C is incorrect because the pain is not necessarily related to the use of a prosthesis. Phantom limb pain can occur regardless of whether a prosthesis is being used. Option D is incorrect because phantom limb pain is a real physiological phenomenon, not purely psychological. While psychological factors can contribute to pain perception, the pain experienced by the patient is not solely psychological and should be treated with appropriate pain management strategies. Educationally, it is essential for nurses to understand the complexities of pain management, especially in unique situations like phantom limb pain. By recognizing the nature of this pain and knowing appropriate interventions like analgesics, nurses can provide optimal care to patients experiencing such discomfort.