The patient with multiple sclerosis tells the nursing assistant that after physical therapy she is too tired to take a bath. What is your priority nursing diagnosis at this time?

Correct Answer: A

Rationale: In this scenario, the correct answer is option A) Fatigue related to disease state. This is the priority nursing diagnosis because fatigue is a common and debilitating symptom of multiple sclerosis (MS). It directly impacts the patient's ability to engage in activities of daily living, such as taking a bath. Addressing fatigue is crucial to improving the patient's quality of life and promoting independence. Option B) Activity Intolerance due to generalized weakness is not the most appropriate choice in this case because it focuses on the patient's inability to tolerate physical activity, rather than addressing the underlying issue of fatigue specifically related to the disease state of MS. Option C) Impaired Physical Mobility related to neuromuscular impairment is not the priority nursing diagnosis in this situation because the patient's main concern is fatigue affecting her ability to perform self-care activities, not solely physical mobility issues. Option D) Self-care Deficit related to fatigue and neuromuscular weakness is not the priority as it combines two aspects (fatigue and neuromuscular weakness) without specifically addressing the primary issue of fatigue and its impact on the patient's ability to engage in self-care activities. Educationally, this question highlights the importance of understanding the unique symptoms and challenges faced by patients with neurological conditions like MS. By prioritizing the nursing diagnosis of fatigue related to the disease state, healthcare providers can tailor interventions to address this specific symptom and support the patient in managing their condition effectively.

Correct Answer: A

Rationale: The most comfortable position for Mr. Tucker would be option A) Supine with head elevated 20-30° and knees flexed. This position helps to reduce pressure on the lower back, promotes proper spinal alignment, and facilitates optimal blood circulation. Elevating the head slightly can also help with breathing and reduce the risk of aspiration in patients with neurological issues. Option B) Prone with head turned to the side and feet extending over the mattress edge is incorrect as it can cause strain on the neck and back, leading to discomfort and potential breathing difficulties. Option C) Flat on the back with the bed gatched in the middle is incorrect as it does not provide adequate support for the spine or promote proper alignment, potentially leading to discomfort and pressure sores. Option D) Supine with a hard thick pillow under the lumbar region is incorrect as it can cause hyperextension of the lumbar spine, leading to discomfort and potential exacerbation of any existing neurological issues. Educationally, understanding the importance of proper positioning for patients with neurological conditions is crucial in preventing complications, promoting comfort, and supporting overall well-being. Teaching healthcare providers about the rationale behind optimal positioning can improve patient care outcomes and enhance their quality of life.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C: Respiratory rate. When Joe arrives in the emergency room, assessing his respiratory rate should be the nurse's priority. This is because an abnormal respiratory rate could indicate immediate life-threatening issues such as compromised airway, respiratory distress, or inadequate oxygenation, which require prompt intervention to ensure patient safety and prevent further deterioration. Option A: Movement of fingers is important for neurological assessment but is not the priority in this situation. Respiratory function takes precedence over extremity movement. Option B: Pain sensation in legs is relevant for assessing neurological function, but it is not as critical as assessing respiratory status in an emergency situation. Option D: Temperature sensation in arms is also important in a neurological assessment, but it is not as urgent as assessing respiratory rate. Educationally, this question highlights the importance of triaging and prioritizing assessments in emergency situations based on the ABCs (Airway, Breathing, Circulation). It reinforces the need for nurses to quickly identify and address life-threatening issues to provide timely and effective care to patients in critical conditions. By understanding the rationale behind prioritizing assessments, nurses can improve their clinical decision-making skills and enhance patient outcomes in emergency settings.

Correct Answer: C

Rationale: In this scenario, the correct answer is option C) express recognition of his difficulty and efforts to communicate. This option is the most appropriate therapeutic approach because it acknowledges the patient's struggle with communication, validates their efforts, and shows empathy. By recognizing the patient's difficulty and efforts, the healthcare provider can help in building a supportive and understanding environment for the patient, which can positively impact their emotional well-being. Option A) anticipate his needs to minimize efforts to talk is incorrect as it does not address the emotional aspect of the patient's reaction. It may inadvertently contribute to the patient feeling misunderstood or not valued for their communication attempts. Option B) respect his need to grieve is also incorrect as aphasia is not typically associated with grieving but rather the frustration of impaired communication. While emotional support is important, grieving might not be the most relevant response in this context. Option D) keep verbal stimulation to a minimum is not the best approach either, as it does not actively address the patient's emotional response to their condition. It may lead to further isolation and frustration for the patient, rather than helping them cope with their feelings. In an educational context, understanding the emotional impact of neurological conditions like aphasia is crucial for healthcare providers. By choosing the appropriate therapeutic approach, providers can not only support patients in their communication challenges but also help improve their overall well-being and quality of life. Effective communication strategies play a significant role in patient-centered care and can enhance the therapeutic relationship between healthcare providers and patients.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) "Those awful muscle spasms have let up." This response indicates that the medication, methocarbamol (Robaxin), has been effective in relieving the muscle spasms, which is its intended therapeutic effect. Mrs. Iris experiencing a reduction in muscle spasms is a positive outcome and suggests that the medication is working as expected. Option A) "I was thirsty after that medication" is unrelated to the effectiveness of methocarbamol in managing muscle spasms. Option B) "I have been urinating a lot today" is not a typical indicator of methocarbamol's effectiveness. Option D) "The swelling in my leg seems to have gone down" is also not a direct indicator of the medication's effectiveness in treating muscle spasms. Educationally, understanding how to assess the effectiveness of medications is crucial for healthcare professionals. It allows them to monitor the patient's response to treatment accurately and make informed decisions regarding ongoing care. In the context of neurological conditions, being able to interpret patient responses to medications is essential for optimizing patient outcomes and ensuring safe and effective management of symptoms.