The patient with a cervical SCI has been placed in fixed skeletal traction with a halo fixation device. When caring for this patient the nurse may delegate which action(s) to the LPN/LVN? (Chooseone that doesn't apply.)

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: Assess the patient's neurologic status for changes. This task requires a higher level of assessment skill and critical thinking, which is typically within the scope of practice of a registered nurse rather than an LPN/LVN. The LPN/LVN can assist with tasks that are more routine and do not require advanced assessment skills. Option A, checking the patient's skin for pressure from the device, is a task that can be safely delegated to the LPN/LVN as it involves basic assessment and monitoring of skin integrity. Option C, observing the halo insertion sites for signs of infection, requires a higher level of assessment to differentiate between normal healing and signs of infection. This task is more appropriate for a registered nurse. Option D, cleaning the halo insertion sites with hydrogen peroxide, involves a specific procedure that may require specialized training or knowledge. It is best performed by a healthcare provider with the appropriate skill set, such as a registered nurse. In an educational context, it is important to understand the principles of delegation in nursing practice. Delegation is a critical skill that ensures safe and efficient patient care delivery. Understanding the scope of practice for different healthcare team members helps in assigning tasks appropriately to optimize patient outcomes and utilize the skills of each team member effectively.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) large output of low specific gravity urine. The pituitary gland plays a crucial role in regulating the body's water balance through the secretion of antidiuretic hormone (ADH). When the pituitary gland is injured, it may affect the production or release of ADH, leading to decreased reabsorption of water in the kidneys and subsequently causing a large output of diluted urine with low specific gravity. Option B) watery nasal discharge positive for glucose is incorrect because this symptom is more indicative of conditions affecting the nasal passages or sinuses, such as a nasal infection or diabetes insipidus. Option C) pupils failing to react to light is incorrect because it is more suggestive of a neurological issue involving the optic nerve or brain, rather than a pituitary gland injury. Option D) positive Babinski reflex is incorrect as it is a response seen in neurological conditions affecting the corticospinal tract, not related to pituitary gland function. Educationally, understanding the signs and symptoms of pituitary gland dysfunction is essential for nurses and healthcare professionals, especially when assessing patients with suspected endocrine disorders. This knowledge helps in early identification, appropriate referral, and management of pituitary gland-related conditions, contributing to better patient outcomes and care.

Correct Answer: D

Rationale: In the context of Mr. Jay receiving levodopa (L-dopa) for Parkinson's disease, the correct answer is D) Rapid reduction of rigidity. Levodopa is a medication commonly used to manage the symptoms of Parkinson's disease, including rigidity, tremors, and bradykinesia. When the medication is taken properly, it should lead to a rapid reduction in rigidity, indicating that it is effectively addressing the symptoms of the disease. Option A) Anorexia, nausea, and vomiting are common side effects of levodopa and do not indicate proper medication administration. Option B) Transient hypertension is not a typical response to levodopa and would not be expected as an indication of proper medication use. Option C) Constipation is not a direct effect of levodopa and does not reflect the expected outcome of taking the medication properly in the context of treating Parkinson's disease. Educationally, understanding the expected outcomes and side effects of medications used in neurological conditions like Parkinson's disease is crucial for healthcare providers to ensure safe and effective patient care. Recognizing the appropriate responses to medications helps in monitoring patient progress and adjusting treatment plans as needed to optimize outcomes.

Correct Answer: D

Rationale: In patients with intracerebral hemorrhage, increased intracranial pressure can lead to a cascade of physiological changes. During the compensatory phase of increased intracranial pressure, the body tries to maintain cerebral perfusion by increasing systemic blood pressure. This increase in blood pressure helps to ensure an adequate blood flow to the brain despite the rising intracranial pressure. Option A, Cheyne-Stokes respiration, is incorrect as it is a pattern of breathing characterized by periods of deep breathing alternating with periods of apnea, typically seen in conditions affecting the brainstem. Option B, an increase in pupil size, is incorrect as changes in pupil size are more indicative of dysfunction in the brainstem or cranial nerve III rather than compensatory changes in response to increased intracranial pressure. Option C, a rapid irregular pulse, is incorrect as it may occur in response to other factors such as pain or anxiety but is not a typical early sign of compensatory changes in intracranial pressure. Educationally, understanding the physiological responses to increased intracranial pressure is crucial for nurses caring for patients with neurological conditions. Recognizing these early signs can prompt timely interventions to prevent further neurological deterioration and improve patient outcomes.

Correct Answer: B

Rationale: In this scenario, the highest priority of care is to continue close monitoring of vital signs and mental status (Option B). This is crucial because the patient is exhibiting signs of a deteriorating condition, including a rise in temperature, pulse, respiration, petechiae, and confusion. Close monitoring will help detect any further changes in the patient's condition promptly, allowing for timely intervention and treatment. Assessing for further signs of infection (Option A) is important in the overall care of the patient, but it is not the highest priority at this moment. The patient is already showing concerning symptoms that require immediate attention. Encouraging fluids and reality orientation measures (Option C) and increasing ventilation by the use of blow bottles (Option D) are not the most appropriate actions to address the current critical situation the patient is facing. These interventions do not directly address the urgent need to monitor and manage the escalating symptoms effectively. From an educational standpoint, this question highlights the importance of prioritizing care based on the patient's condition and the urgency of the situation. It underscores the significance of prompt assessment and monitoring in identifying changes in a patient's status and initiating timely interventions to ensure patient safety and well-being.