The nurse instructs a client who has a neurological deficit regarding nutrition and diet. What should the client do?

Correct Answer: D

Rationale: The correct answer to the question is option D, which states, "Be sure to take fluids frequently." This is the most appropriate advice for a client with a neurological deficit related to nutrition and diet for several reasons. Neurological deficits can affect swallowing function, leading to an increased risk of dehydration and aspiration. Encouraging the client to take fluids frequently helps maintain hydration, aids in swallowing, and prevents complications such as aspiration pneumonia. Option A, eating two large meals instead of frequent small meals, is incorrect because it can overload the digestive system, especially for individuals with neurological deficits that may have difficulty with digestion and absorption. Consuming smaller, more frequent meals is generally recommended for better nutrient absorption and energy distribution throughout the day. Option B, consuming a diet low in fiber, is also incorrect. Fiber is essential for digestive health and regular bowel movements. A diet low in fiber can lead to constipation, which can be exacerbated in individuals with neurological deficits who may already have gastrointestinal issues. Option C, chewing foods quickly, is incorrect as well. Clients with neurological deficits may have difficulty with chewing and swallowing, which can increase the risk of choking and aspiration. Chewing food thoroughly and slowly is important to prevent these risks and aid in digestion. In an educational context, it is crucial for nurses to provide tailored nutrition and diet advice to clients with neurological deficits to promote optimal health and prevent complications. Understanding the specific needs and challenges faced by these individuals is essential in developing appropriate dietary recommendations that support their overall well-being. Encouraging frequent fluid intake is a simple yet effective strategy to address hydration and swallowing issues commonly seen in this population.

Correct Answer: C

Rationale: The correct answer is C: Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. This is the most appropriate answer because spinal shock is a temporary condition that occurs immediately after a spinal cord injury and is characterized by a loss of reflexes, flaccid paralysis, and absence of sensation below the level of injury. As the spinal shock resolves, the signs mentioned in option C begin to appear, indicating the return of reflex activity. Option A is incorrect because rehabilitation measures can actually begin during spinal shock to prevent complications and promote optimal recovery. Option B is incorrect because while continuous monitoring for hypotension, tachycardia, and hypoxemia is important in spinal cord injury patients, it is not specific to spinal shock resolution. Option D is incorrect because autonomic functions can be affected in spinal shock, leading to issues such as hypotension and bradycardia. In an educational context, understanding the progression of spinal shock and its resolution is crucial for nurses caring for patients with spinal cord injuries. Recognizing the signs of spinal shock resolution helps in planning appropriate care and interventions to support the patient's recovery and prevent complications. It is essential for nurses to be knowledgeable about neurological assessments, spinal cord injury management, and the implications of spinal shock to provide effective and evidence-based care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible. This is because in a male patient with a complete lower motor neuron lesion, there is disruption in the communication between the spinal cord and the brain, leading to impaired voluntary control over sexual function. Reflex erections can still occur due to intact reflex pathways, but the coordination required for ejaculation and orgasm is typically lost. Option A is incorrect because although reflexogenic erections may occur, the ability to achieve orgasm is usually impaired without ejaculation. Option C is incorrect because a complete lower motor neuron lesion would actually affect both psychogenic and reflexogenic erections. Option D is also incorrect as it generalizes the outcome without considering the possibility of reflex erections. In an educational context, it is important for nurses to understand the specific effects of spinal cord lesions on sexual function to provide accurate counseling to patients. By knowing the nuances of how different types of lesions impact sexual responses, nurses can better support patients in managing their expectations and exploring potential interventions to enhance their quality of life.

Correct Answer: C

Rationale: In the context of assessing joint range of motion in a patient with severe joint immobility undergoing physical and exercise therapy, the correct equipment to use is a goniometer (Option C). A goniometer is a tool specifically designed to measure the angle of a joint. The correct answer is right because a goniometer allows the nurse to accurately measure the degree of movement in a joint, which is crucial in evaluating the effectiveness of the therapy. By using a goniometer, the nurse can track changes in the joint range of motion over time and adjust the treatment plan accordingly. Option A, an ergometer, is used to measure work output during exercise and is not suitable for assessing joint range of motion. Option B, a myometer, measures muscle strength and is not designed for joint angle assessment. Option D, an arthrometer, is not a standard tool used for measuring joint range of motion. Educationally, understanding the correct equipment for assessing joint range of motion is essential for nurses caring for patients with musculoskeletal issues. Proper assessment tools ensure accurate monitoring of progress and help in providing effective care tailored to the patient's needs. Mastering the use of a goniometer is a fundamental skill for nurses working in rehabilitation and orthopedic settings.

Correct Answer: B

Rationale: The correct answer is B) Sprains and strains. RICE (rest, ice, compression, and elevation) is a standard protocol for the initial management of acute injuries like sprains and strains. Rest helps prevent further damage and allows the body to begin the healing process. Ice reduces pain, inflammation, and swelling by constricting blood vessels. Compression helps control swelling and provides support to the injured area. Elevation reduces swelling by aiding in the drainage of excess fluid. Option A) Muscle spasms do not typically require RICE as they are more related to muscle contractions and not acute injuries requiring the same level of management. Option C) Repetitive strain injury is a chronic overuse injury that may require rest and activity modification but does not typically call for the immediate RICE protocol. Option D) Dislocations and subluxations are more severe injuries that typically require immediate medical attention and possible reduction techniques, rather than just RICE. In an educational context, understanding the application of RICE is crucial for nurses and healthcare professionals in managing acute injuries effectively. Knowing when to implement this protocol can help promote optimal recovery and prevent further complications in patients with sprains and strains.