Mr. Sands continues to be quiet and withdrawn several days after admission. Besides Raynaud phenomenon, he has generalized telangiectasis. He seldom initiates conversation, and although up ad lib, he rarely leaves his room. Which one of the following goals would be most important to develop in his nursing care plan?

Correct Answer: C

Rationale: In this scenario, the most important goal for Mr. Sands in his nursing care plan would be to enhance self-concept (Option C). Mr. Sands is exhibiting signs of social withdrawal and isolation, which could be indicative of underlying psychological or emotional distress. By focusing on enhancing his self-concept, the nursing care plan can address his psychological well-being, self-esteem, and overall mental health. Option A, providing for solitude and rest, may exacerbate Mr. Sands' isolation and contribute to his withdrawal. It is important to strike a balance between allowing for personal time and promoting social interaction. Option B, protecting from temperature extremes, is not the most pressing issue in this case as it does not directly address Mr. Sands' emotional and psychological state. Option D, moving to a four-bed ward, does not address the underlying issue of social withdrawal and may not necessarily improve Mr. Sands' condition. Educationally, this question highlights the importance of considering the holistic needs of patients, including their psychological well-being, in addition to physical health. It emphasizes the role of nursing in promoting mental health and supporting patients in developing a positive self-concept. By understanding the rationale behind choosing the correct answer, nurses can better tailor care plans to meet the individual needs of each patient.

Correct Answer: C

Rationale: In this scenario, applying a cold pack to the area where the needle electrodes were inserted is the most appropriate nursing intervention to relieve the client's discomfort after electromyography tests. Cold packs help constrict blood vessels, reduce inflammation, and numb the area, thereby alleviating pain and discomfort. Option A, administering topical analgesics, may not be as effective as cold therapy in reducing pain and inflammation in this case. Massaging the area (Option B) could potentially exacerbate the discomfort and irritation at the needle insertion site. Applying warm compresses (Option D) may increase blood flow and inflammation, leading to more pain and discomfort. From an educational perspective, it is crucial for nurses to understand the rationale behind using cold therapy for pain relief after certain procedures. By comprehending the physiological effects of cold packs on the body, nurses can make informed decisions to provide optimal care and comfort to their patients, especially in situations involving post-procedural discomfort like in this case.

Correct Answer: C

Rationale: The correct answer is C) Physical therapy. Physical therapy plays a crucial role in the rehabilitation process for a client recovering from a ruptured Achilles tendon. Physical therapists are trained to design individualized treatment plans to help regain mobility, strength, and the full range of motion. They use specific exercises, manual techniques, modalities, and therapeutic activities to promote healing and improve function. Option A) Regular use of NSAIDs is not the most appropriate measure for regaining mobility, strength, and range of motion. While NSAIDs may help with pain management, they do not address the underlying issues of muscle strength and joint flexibility. Option B) Vigorous exercise may be contraindicated in the early stages of Achilles tendon recovery as it can put excessive stress on the healing tendon, leading to further damage or delayed healing. Option D) Non-medical interventions like yoga can be beneficial for overall flexibility and stress reduction, but they may not provide the targeted rehabilitation needed for a ruptured Achilles tendon. Yoga alone may not be sufficient to address the specific needs of this injury. In an educational context, it is important for nurses to understand the role of different interventions in the rehabilitation process post-injury. By recommending physical therapy, nurses can ensure that their clients receive the specialized care needed to achieve optimal recovery outcomes. Collaboration with physical therapists allows for a holistic approach to care, addressing both physical and functional aspects of healing.

Correct Answer: B

Rationale: The correct answer is B) MRI with gadolinium showing demyelination of nerve fibers. Multiple sclerosis (MS) is a chronic autoimmune disease that affects the central nervous system, leading to inflammation and damage to the myelin sheath surrounding nerve fibers. An MRI with gadolinium is a common diagnostic test for MS as it can visualize areas of demyelination and inflammation in the brain and spinal cord, which are characteristic of the disease. Option A) CBC with a very low WBC count is incorrect because MS does not typically present with abnormalities in white blood cell counts. Option C) Endocrine function study with a low growth hormone and high T3 and T4 is incorrect as these abnormalities are not associated with MS. Option D) Fasting glucose test with a result over 300 mg/dL is incorrect as it is indicative of diabetes mellitus, not multiple sclerosis. In an educational context, understanding the diagnostic process for neurological conditions like multiple sclerosis is crucial for healthcare professionals. By knowing the appropriate tests and their significance, healthcare providers can ensure timely and accurate diagnosis, leading to better patient outcomes. MRI with gadolinium remains a cornerstone in diagnosing MS due to its ability to visualize the structural changes in the central nervous system associated with the disease.

Correct Answer: B

Rationale: In providing discharge instructions to a post-operative carpal tunnel syndrome (CTS) patient, it is crucial to ensure they have the necessary information for a successful recovery. Option B, "Hand movements will be restricted for 4-6 weeks after surgery," is the correct answer. This information is essential as it highlights a key aspect of post-operative care for CTS patients. Restricting hand movements helps to promote proper healing and prevent complications such as excessive strain on the surgical site. Option A, "The surgical procedure is a cure for CTS," is incorrect because while surgery can effectively relieve symptoms of CTS, it is not always a guaranteed cure, and patients may still need to manage their condition post-operatively. Option C, "Frequent pain medication dosages will no longer be necessary," is incorrect as post-operative pain management is often required, especially in the immediate aftermath of surgery. Patients should be informed about the pain management plan prescribed by their healthcare provider. Option D, "Notify the physician immediately for any pain or discomfort," is also important but not as crucial as the correct answer. While it is essential for patients to report any concerning symptoms to their healthcare provider, understanding the need for restricted hand movements is more directly related to the immediate post-operative care and outcomes for a CTS patient. Educationally, understanding the specific post-operative care requirements for different surgical procedures is vital for healthcare providers to ensure optimal patient outcomes. Providing accurate and detailed discharge instructions helps patients take an active role in their recovery and minimizes the risk of complications. By choosing the correct answer, healthcare providers can contribute to the overall well-being and successful recovery of their patients undergoing CTS surgery.