For a patient with a one-sided spinal injury, the nurse must be careful about the temperature of the bath water because the patient's temperature sensation is lost

Correct Answer: A

Rationale: In a patient with a one-sided spinal injury, the loss of temperature sensation on the affected side can lead to difficulties in detecting extreme temperatures, potentially resulting in burns or hypothermia. The correct answer, option A) contralaterally below the injury, is the most appropriate because temperature sensation is lost on the opposite side of the injury. This means that the patient may not feel if the water is too hot or too cold on the side opposite to the injury site, making it crucial to monitor the temperature carefully. Options B, C, and D are incorrect because they do not consider the specific loss of temperature sensation contralaterally to the injury site. Choosing option B) ipsilaterally below the injury suggests that the temperature sensation is lost on the same side as the injury, which is inaccurate. Option C) bilaterally below the injury implies that the loss of temperature sensation occurs on both sides below the injury, which is not consistent with the neuroanatomical pathways. Option D) contralaterally above the injury is incorrect as the loss of sensation typically occurs below the level of the spinal injury. Educationally, understanding the neurological implications of spinal cord injuries is crucial for nurses to provide safe and effective care. By grasping the sensory deficits associated with specific injury sites, nurses can implement appropriate interventions to prevent complications and ensure the well-being of patients with spinal cord injuries. Monitoring bath water temperature is just one practical application of this knowledge that can significantly impact patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) "I draw the kneecap toward the thigh, hold for 5 seconds and relax." This response demonstrates an understanding of isometric exercises, which involve contracting a muscle without changing its length. By describing the action of drawing the kneecap toward the thigh and holding for a specific duration, the patient shows comprehension of how to perform the exercise correctly. Option A is incorrect because it mentions pulling on a traction rope, which is not typically used in isometric exercises and does not reflect an understanding of the correct technique. Option C involves using a trapeze to lift oneself off the bed, which is not an isometric exercise but rather an activity requiring dynamic movement. Option D describes turning to the right side, which is unrelated to the task of isometric muscle-setting exercises. In an educational context, it is crucial for patients to understand and perform exercises correctly to benefit from their therapeutic effects. By providing clear instructions and ensuring patient comprehension, healthcare professionals can help patients engage in appropriate rehabilitation or strengthening activities to support their neurological health and recovery.

Correct Answer: B

Rationale: The most important aspect to include in the nursing care plan preoperatively for Mr. Singer, who is scheduled for a hip replacement due to severe rheumatoid arthritis, is option B: Active and passive range-of-motion exercises. Engaging in these exercises before surgery can help maintain joint mobility, prevent stiffness, and improve overall postoperative outcomes. Option A: Adequate periods of rest may be important for recovery but focusing solely on rest without addressing joint mobility can lead to decreased range of motion and increased risk of complications post-surgery. Option C: Maintenance of adequate fluid and food is important for overall health but may not have a direct impact on the success of the hip replacement surgery. Option D: Frequent turning and repositioning is crucial for preventing pressure ulcers in immobile patients but does not address the specific need for joint mobility preoperatively in this case. Educational context: Preoperative nursing care plans are tailored to each patient's specific needs to optimize outcomes. In cases like Mr. Singer's, focusing on maintaining joint mobility through range-of-motion exercises is crucial for successful postoperative rehabilitation and recovery.

Correct Answer: A

Rationale: In a patient with periarteritis nodosa, it is most important to ask questions related to dysfunction of the cardiovascular system. Periarteritis nodosa is a systemic vasculitis that primarily affects medium-sized arteries, leading to inflammation and damage to blood vessels. This can result in serious cardiovascular complications such as hypertension, aneurysms, and organ ischemia. Option A, cardiovascular, is the correct choice because the disease directly impacts the blood vessels and heart, making it crucial to monitor and address any dysfunction in these areas. Option B, renal, may also be affected in periarteritis nodosa due to compromised blood flow to the kidneys, but the primary focus should be on the cardiovascular system due to the nature of the disease. Option C, visual, is less likely to be affected in periarteritis nodosa compared to the cardiovascular system. While eye involvement can occur in some cases, it is not the most critical system to monitor in this condition. Option D, immunologic, is important in understanding the underlying cause of periarteritis nodosa (an autoimmune reaction), but in terms of immediate health history assessment, cardiovascular dysfunction poses the most significant risk to the patient's well-being. Educationally, understanding the importance of focusing on specific systems in different diseases helps healthcare providers prioritize their assessments and interventions, leading to better patient outcomes. It also highlights the interconnectedness of bodily systems and how dysfunction in one area can impact others.

Correct Answer: B

Rationale: In this scenario, option B, which is palpating the muscles and joints, is the correct method to help a nurse identify swelling in a client who has experienced a musculoskeletal injury to her hip. Palpation involves using touch to feel for abnormalities such as swelling, tenderness, or warmth in the affected area. Swelling is often palpable due to the increase in fluid accumulation in the tissues surrounding the injury site. Option A, asking questions about pain severity, may provide information on the client's subjective experience but may not directly identify swelling. Option C, asking the client to move the injured area, could potentially exacerbate the injury or cause further damage if there is swelling present. Option D, observing for involuntary movements, is more relevant for assessing neurological issues rather than identifying swelling. In an educational context, it is crucial for nurses to understand the proper techniques for assessing musculoskeletal injuries to provide accurate care and treatment. Palpation is a fundamental skill that allows healthcare providers to gather important information about the client's condition, including identifying swelling, tenderness, or other abnormalities. By mastering palpation techniques, nurses can enhance their assessment skills and provide better care for clients with musculoskeletal injuries.