The patient is diagnosed with torticollis. What should the nurse be prepared to provide for the patient?

Correct Answer: B

Rationale: In the case of a patient diagnosed with torticollis, the correct action for the nurse to provide is option B) Exercises to increase the strength of the muscles. Torticollis, also known as wry neck, is a condition characterized by a twisted or tilted neck due to involuntary muscle contractions. By engaging in specific exercises, the patient can help improve muscle strength and flexibility, which can alleviate the symptoms of torticollis over time. Option A) An immobilizer to hold the bones in place is incorrect because torticollis is primarily a muscular issue rather than a problem with bones that need immobilization. Using an immobilizer would not address the underlying cause of the condition. Option C) A pillow to use to support the knees while sleeping and Option D) Enough pillows to support the patient's head comfortably are also incorrect as they do not directly target the muscles of the neck that are affected in torticollis. While supportive pillows may provide some comfort, they do not address the need for muscle strengthening to improve the condition. From an educational standpoint, understanding the rationale behind the correct answer not only reinforces knowledge of torticollis but also highlights the importance of non-pharmacological interventions such as exercises in managing musculoskeletal conditions. Nurses play a vital role in educating patients on self-care strategies like exercises, empowering them to actively participate in their treatment and recovery process.

Correct Answer: C

Rationale: The correct answer is C) Provide a quiet, dimly lit environment to reduce stimuli that increase muscle tension and anxiety. This intervention is appropriate because it directly addresses the environmental factors that can contribute to exacerbating anxiety in a patient with a headache. A quiet and dimly lit environment can help reduce sensory stimuli, promoting relaxation and potentially alleviating the patient's anxiety. Option A) Help the patient to examine lifestyle patterns and precipitating factors is not the most appropriate intervention in this context as it focuses more on identifying contributing factors rather than addressing the immediate need to reduce anxiety. Option B) Administer medications as ordered to relieve pain and promote relaxation may be necessary for pain relief but does not directly address the anxiety related to lack of knowledge about the headache etiology and treatment. Educationally, it is important for nurses to understand the holistic approach to patient care, considering not only the physical symptoms but also the psychological and environmental factors that can impact a patient's well-being. Providing a calm and soothing environment is a non-invasive, patient-centered intervention that can help manage anxiety and promote comfort in patients experiencing headaches.

Correct Answer: C

Rationale: In this scenario, option C, "Weakness of one leg resulting in a limping walk," is the most indicative of Parkinson's disease. Parkinson's disease is a neurodegenerative disorder characterized by motor symptoms like bradykinesia, rigidity, tremors, and postural instability. The weakness in one leg leading to a limping walk can be a manifestation of bradykinesia and muscle rigidity commonly seen in Parkinson's patients. Option A, "Large embellished handwriting," is more suggestive of a condition called micrographia, where handwriting becomes smaller and more cramped in Parkinson's disease, not larger and embellished as described in the option. Option D, "Difficulty rising from a chair and beginning to walk," is a common symptom in Parkinson's disease due to bradykinesia and rigidity, but weakness in one leg resulting in a limping walk is more specific to Parkinson's and aligns better with the typical gait disturbances seen in this condition. Educationally, understanding the specific motor symptoms of Parkinson's disease is crucial for nurses to recognize the early signs and provide appropriate care and support to patients. Assessing gait abnormalities, like a limping walk due to leg weakness, can help in early detection and timely intervention in Parkinson's disease. This knowledge enhances the nurse's ability to collaborate with the healthcare team in managing Parkinson's patients effectively.

Correct Answer: B

Rationale: In caring for patients with Alzheimer's Disease (AD), drug therapy for cognitive problems and undesirable behaviors is a crucial aspect of collaborative care. The correct answer, option B, is the most appropriate because medications can help manage symptoms such as memory loss and behavioral changes associated with AD. Drugs like cholinesterase inhibitors and memantine are commonly used to improve cognitive function and manage behavioral symptoms. Option A, replacement of deficient acetylcholine in the brain, is incorrect because while acetylcholine levels are reduced in AD, simply replacing it has not been shown to effectively treat the disease. Option C, the use of memory-enhancing techniques to delay disease progression, is incorrect because while cognitive stimulation activities may benefit patients in the early stages, they do not alter the course of the disease. Option D, prevention of other chronic diseases that hasten the progression of AD, is incorrect as it focuses on general health measures rather than specific AD treatment. Educationally, understanding the rationale behind the correct answer helps students grasp the importance of pharmacological interventions in managing AD symptoms. It also emphasizes the need for evidence-based practices in dementia care, highlighting the limitations of non-pharmacological approaches in altering disease progression. This question reinforces the significance of tailored treatment plans and interdisciplinary collaboration in providing optimal care for patients with neurological disorders.

Correct Answer: B

Rationale: The correct answer is B) The status of tetanus immunization. When a patient presents with an open fracture, there is a risk of tetanus infection due to exposure to dirt or foreign bodies. Tetanus is a serious bacterial infection that can lead to muscle stiffness and spasms, which can be life-threatening. Therefore, knowing the patient's tetanus immunization status is crucial for timely intervention. Option A) Any previous injuries to the leg is not directly related to the immediate management of an open fracture and tetanus prevention. While it may provide some historical context, it is not as critical as tetanus immunization status in this scenario. Option C) The use of antibiotics in the last month is important in general medical history taking but is not as directly relevant to the prevention of tetanus in the setting of an open fracture. Option D) Whether the injury was exposed to dirt or gravel is related to the mechanism of injury, but the focus should be on the potential for tetanus infection and the need for immunization. In an educational context, this question highlights the importance of thorough assessment in patients with open fractures, emphasizing the need to prioritize information gathering based on the immediate risks associated with the condition. Understanding the rationale behind prioritizing specific questions can help nurses make informed clinical decisions and provide optimal care to patients in similar situations.