The patient with migraine headaches has a seizure. After the seizure, which action can you delegate to the nursing assistant?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Take the patient's vital signs. Delegating the task of taking vital signs to the nursing assistant is appropriate as it is a non-invasive procedure that does not require advanced medical knowledge. Vital signs are essential parameters to monitor the patient's condition post-seizure, helping to assess stability or potential complications. Option A, documenting the seizure, requires a higher level of critical thinking and understanding of medical terminology, making it inappropriate for delegation to a nursing assistant. Option B, performing neurologic checks, involves assessing complex neurological functions that require specialized training and knowledge, making it unsuitable for delegation. Option D, restraining the patient for protection, should never be delegated to a nursing assistant as it involves physical restraint, which is a high-risk intervention requiring specialized training to ensure patient safety and prevent harm. From an educational standpoint, understanding the rationale behind delegation in such situations is crucial for nurses to provide safe and effective care. Delegation is a key skill in nursing practice, but it must be done thoughtfully, considering the complexity of tasks, individual competency levels, and patient safety. Nurses must be able to differentiate between tasks that can be delegated and those that require their direct involvement to ensure the best outcomes for patients.

Correct Answer: C

Rationale: The correct answer to the question is option C, the 46-year-old patient admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the best choice for the RN from the medical unit because bacterial meningitis requires close monitoring, timely administration of antibiotics, and ongoing assessment for any changes in neurological status. The RN from the medical unit would likely have more experience and comfort managing infectious conditions and administering antibiotics compared to the other neurologically complex cases presented in the question. Option A, the 26-year-old patient with a basilar skull fracture and clear drainage coming out of the nose, requires specialized neurologic care due to the risk of cerebrospinal fluid leak and potential complications. Option B, the 42-year-old patient with a ruptured berry aneurysm, also needs specialized care in a neuro ICU setting for monitoring and potential interventions related to the aneurysm. Option D, the 65-year-old patient with an astrocytoma who just had a craniotomy, requires specialized neurosurgical care and monitoring postoperatively. Providing this educational context helps students understand the importance of matching the complexity and acuity of patients with the appropriate level of nursing expertise to ensure safe and effective care delivery, especially in critical care settings like the neurologic ICU.

Correct Answer: D

Rationale: In this scenario, option D is deemed inappropriate because it suggests turning the patient on his side by moving the shoulders and upper trunk first, which can strain the back muscles. This method puts excessive pressure on the back and can lead to injury. Option A is correct as it recommends using a turning sheet to logroll the patient onto a bedpan, minimizing strain on the back muscles. Option B is also appropriate as it supports proper alignment by placing a pillow between the knees when lying on the side. Option C is suitable as it helps maintain proper alignment by placing pillows under the knees when lying on the back. Educationally, it is crucial for nurses to understand and implement proper body mechanics to prevent injury to both patients and themselves. Teaching correct techniques for repositioning patients is essential in maintaining their comfort and preventing musculoskeletal issues. Nurses must always prioritize patient safety and well-being by utilizing appropriate methods for patient care.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) lack of muscle activity results in poor circulation. Turning a patient every 2 hours is a crucial preventive measure to avoid developing decubitus ulcers or pressure sores. When a patient is immobile or paralyzed, the lack of movement can lead to pressure on certain areas of the body, reducing circulation to those areas. This restricted blood flow can cause tissue damage, leading to the formation of ulcers. Option A is incorrect because while nutritional requirements may be increased in paralyzed patients, it is not the primary reason for developing decubitus ulcers. Option B is incorrect as muscle spasms causing flexion contractures may contribute to the risk of pressure sores, but it is not the primary reason for their development. Option C is also incorrect as retention of waste products causing metabolic acidosis is not directly linked to the formation of decubitus ulcers. Educationally, understanding the rationale behind turning immobile patients helps students grasp the importance of preventive nursing care. It reinforces the significance of maintaining proper circulation to prevent complications such as pressure ulcers, highlighting the holistic care approach needed for patients with limited mobility. This knowledge is vital for nurses to provide effective care and prevent potential complications in their patients.

Correct Answer: D

Rationale: The correct answer is D) ability to transfer from bed to chair. In the context of a hemiplegic patient, the ability to transfer from bed to chair is a crucial initial step in achieving the goal of ambulation. This skill is essential as it directly impacts the patient's functional independence and mobility. Mastering the transfer from bed to chair requires the patient to engage and coordinate various muscle groups, improve balance, and enhance overall strength. It serves as a foundational skill that sets the stage for more advanced mobility tasks like walking. Option A) acceptance of his altered body image may be an important psychological aspect of the patient's overall well-being, but it is not the immediate priority in achieving ambulation. Option B) balance training is important in the rehabilitation process, but without the ability to transfer from bed to chair, the patient would not be able to progress to more advanced training. Option C) adequate energy level is necessary for participation in therapy sessions and activities, but it is not the primary factor in achieving ambulation for a hemiplegic patient. In an educational context, understanding the hierarchy of goals in the care plan for a hemiplegic patient is crucial for healthcare professionals to provide effective rehabilitation. By prioritizing tasks such as mastering transfers, healthcare providers can ensure a systematic and goal-oriented approach to rehabilitation that maximizes the patient's potential for recovery and independence.