The nurse positions a client who is being treated for a fracture. Why should care be taken to position the client's joints in an anatomic alignment?

Correct Answer: D

Rationale: In the context of positioning a client with a fracture, it is crucial to ensure that the joints are positioned in an anatomic alignment to prevent damage to the peripheral nerves and blood vessels, making option D the correct answer. When joints are not in proper alignment, there is a risk of compression or injury to the surrounding nerves and blood vessels due to increased pressure or tension on these structures. This can lead to complications such as impaired circulation, numbness, tingling, or even more serious nerve damage. Option A, to prevent deep vein thrombosis, is incorrect in this scenario because deep vein thrombosis is more related to immobility and blood clot formation in the deep veins, rather than joint alignment. Option B, to facilitate lung expansion and prevent pooling of secretions, is not directly related to joint alignment in a client with a fracture. Option C, to prevent the escalation of pain and swelling, is important but not the primary reason for ensuring anatomic alignment of joints. Educationally, understanding the rationale behind proper positioning in clients with fractures is essential for nurses to provide safe and effective care, prevent complications, and promote optimal healing and recovery. It highlights the importance of attention to detail and precision in nursing interventions to promote positive patient outcomes.

Correct Answer: C

Rationale: In the context of preparing a patient with carpal tunnel syndrome for surgery, delegating assisting the patient with daily self-care measures such as bathing and eating to the nursing assistant is the most appropriate intervention. This task falls within the scope of the nursing assistant's role and is essential for ensuring the patient's comfort and hygiene during the pre-operative period. Option A, initiating the placement of a splint for immobilization during the day, involves a more specialized skill that should be performed by a licensed healthcare provider, such as a nurse or physician. While assessing the patient's wrist and hand for discoloration and brittle nails (Option B) is important in the overall assessment of carpal tunnel syndrome, it is not directly related to preparing the patient for surgery. Testing the patient for painful tingling in the four digits of the hand (Option D) is a clinical assessment task that requires specialized knowledge and should be performed by a nurse or healthcare provider. Delegating appropriate tasks to the nursing assistant not only optimizes the efficiency of care but also ensures that each team member is working within their scope of practice, promoting safe and effective patient care.

Correct Answer: D

Rationale: The correct answer is D) Central nervous system. When a client is undergoing neurological testing for a brain tumor, it primarily affects the central nervous system (CNS) because the brain tumor is located within the brain or spinal cord, which are components of the CNS. Testing for a brain tumor involves assessing the structures and functions of the brain and spinal cord, which are part of the CNS. Option A) Peripheral nervous system is incorrect because the peripheral nervous system consists of nerves outside the brain and spinal cord, and a brain tumor does not directly affect these peripheral nerves. Option B) Autonomic nervous system is incorrect because while the autonomic nervous system is a division of the peripheral nervous system that regulates involuntary bodily functions like heart rate and digestion, it is not the primary division affected by a brain tumor. Option C) Sympathetic nervous system is incorrect because it is a part of the autonomic nervous system, which as mentioned earlier, is not the main division affected in a client with a brain tumor. Educationally, understanding the divisions of the nervous system is crucial for healthcare professionals as it helps in accurate assessment, diagnosis, and treatment of neurological conditions. Knowing which division is primarily affected in specific conditions like brain tumors guides healthcare providers in providing appropriate care and interventions.

Correct Answer: D

Rationale: In this scenario, the nurse should suspect Myasthenia gravis (MG) based on the client's symptoms of ptosis, difficulty chewing and swallowing, diplopia, voice weakness, masklike facial expression, and extremity weakness. MG is an autoimmune neuromuscular disorder characterized by muscle weakness and fatigue. These specific symptoms align with the hallmark features of MG due to the involvement of the neuromuscular junction. Option A, Parkinson's disease, is characterized by tremors, rigidity, bradykinesia, and postural instability, not the symptoms described in the question. Option B, Extrapyramidal disorder, encompasses a group of movement disorders affecting the extrapyramidal system but does not typically present with the specific combination of symptoms mentioned. Option C, Multiple sclerosis, is a central nervous system disorder that involves demyelination of nerve fibers, leading to a variety of symptoms, but it does not typically cause the specific neuromuscular junction-related symptoms seen in this case. Educationally, understanding the distinct clinical manifestations of different neurological conditions is crucial for accurate diagnosis and effective patient care. Recognizing the specific symptoms associated with MG can aid nurses in providing timely interventions, such as administering acetylcholinesterase inhibitors or immunosuppressants, and monitoring for myasthenic crises. This case underscores the importance of clinical assessment, knowledge of pathophysiology, and critical thinking in the care of patients with neurological conditions.

Correct Answer: D

Rationale: Urinary retention is a common issue in older adults with neurologic deficits due to impaired bladder function. The correct answer, "D) A behavior change," is indicative of urinary retention because individuals may exhibit behaviors such as restlessness, agitation, or increased confusion due to the discomfort caused by the inability to empty their bladder. Option A, "Amnesia," is not a sign of urinary retention but rather a memory-related issue. Option B, "Hypotension," and Option C, "Hypertension," are related to blood pressure regulation and are not directly associated with urinary retention in this context. Educationally, understanding the signs of urinary retention in older adults with neurologic deficits is crucial for healthcare providers to provide timely interventions and prevent complications such as urinary tract infections and bladder distention. Recognizing behavioral changes can prompt further assessment and appropriate management to improve the patient's comfort and prevent potential complications.