To assist a patient diagnosed with a somatic system disorder, a nursing intervention of high priority is to:

Correct Answer: C

Rationale: Rationale for Choice C: Shifting the focus from somatic symptoms to feelings is crucial as it helps address the underlying emotional factors contributing to the somatic system disorder. By exploring the patient's emotions and addressing them, the nurse can help the patient gain insight into their condition and potentially reduce the somatic symptoms. This intervention promotes holistic care by addressing both physical and emotional aspects of the disorder. Summary of other choices: A: Implying that somatic symptoms are not real can invalidate the patient's experience and hinder therapeutic progress. B: Helping the patient suppress feelings of anger can lead to emotional repression and exacerbate somatic symptoms. D: Investigating each physical symptom as soon as it is reported may overlook the emotional root causes of the somatic system disorder.

Correct Answer: B

Rationale: In this scenario, the correct action to delegate to the nursing assistant when caring for a patient with a spinal cord injury (SCI) is option B: take the patient's vital signs and record them every 4 hours. This task is appropriate for delegation to a nursing assistant because it is within their scope of practice and does not require advanced nursing assessment skills. Vital signs are crucial indicators of a patient's overall health status, especially for patients with SCI who may be at risk for complications such as autonomic dysreflexia or neurogenic shock. Regular monitoring of vital signs can help detect early signs of deterioration or improvement in the patient's condition. The other options are not the best choices to delegate to a nursing assistant in this situation because: - Option A requires assessing respiratory status, which involves more complex assessment skills and interpretation that are typically within the scope of a licensed nurse. - Option C involves monitoring nutritional status and calorie counts, which requires a more specialized understanding of nutrition and dietetics. - Option D involves assisting the patient with turning, coughing, and deep breathing, which requires direct patient care and physical assistance that is typically performed by nursing assistants under the supervision of licensed nurses. In an educational context, understanding the principles of delegation is crucial for nurses to effectively prioritize and distribute tasks among healthcare team members based on their scope of practice and competency levels. Nurses must ensure that tasks are delegated appropriately to promote patient safety and quality care delivery.

Correct Answer: B

Rationale: In this scenario, the correct patient to assess first is option B, the 45-year-old scheduled for a craniotomy in 30 minutes who needs preoperative teaching. This patient takes priority due to the impending surgical procedure, requiring immediate attention to ensure understanding of the process, potential risks, and postoperative care. Preoperative teaching is crucial for informed consent, anxiety reduction, and optimal surgical outcomes. Option A, the 23-year-old with a migraine and severe nausea, while in discomfort, does not have an urgent procedure or immediate risk that would warrant assessment before the patient scheduled for surgery. Option C, the 59-year-old with Parkinson's disease needing a swallowing assessment, is important but can be done after addressing the imminent surgical case. Option D, the 63-year-old with multiple sclerosis and a fever, presents with concerning symptoms but does not have an urgent procedure scheduled like the patient in option B. The fever and flank pain require assessment and intervention but can be addressed after attending to the patient needing preoperative teaching. Educationally, understanding prioritization in nursing care is vital. This scenario highlights the importance of triaging patients based on acuity, urgency, and potential risks. It emphasizes the significance of time management, critical thinking, and decision-making in providing safe and effective patient care. Prioritizing care ensures that the most critical needs are addressed promptly, leading to better outcomes for patients.

Correct Answer: A

Rationale: In the scenario presented, Mr. Smith is experiencing signs of increased intracranial pressure, a serious condition that requires immediate intervention. The correct medication likely to be ordered for Mr. Smith in this situation is A) Mannitol. Mannitol is an osmotic diuretic that works by reducing cerebral edema and intracranial pressure. It does this by drawing water out of brain tissue and into the bloodstream, ultimately decreasing the pressure inside the skull. Now, let's discuss why the other options are incorrect: - B) Insulin: Insulin is not used to treat increased intracranial pressure. Its primary role is to regulate blood sugar levels in the body. - C) Morphine sulfate: Morphine sulfate is an opioid analgesic used for pain relief and is not indicated for managing increased intracranial pressure. - D) Penicillin: Penicillin is an antibiotic used to treat bacterial infections and has no direct impact on reducing intracranial pressure. Educational context: Understanding the appropriate medications for managing increased intracranial pressure is crucial for healthcare professionals, especially those working in critical care settings. Knowledge of medications like Mannitol and their mechanisms of action is vital in providing timely and effective care to patients with neurological emergencies.

Correct Answer: C

Rationale: Rationale: The correct answer is C) assisting with activities of daily living. In Parkinson's disease, a neurodegenerative disorder affecting movement, muscle control, and balance, patients often experience a range of motor and non-motor symptoms. One of the hallmark features of Parkinson's is the progressive loss of ability to perform activities of daily living independently due to muscle rigidity, tremors, and bradykinesia. Therefore, assisting with activities of daily living such as grooming, dressing, eating, and mobility becomes a major nursing need to maintain Mrs. Moore's quality of life. Option A) monitoring for seizures is incorrect as seizures are not a typical manifestation of Parkinson's disease. Option B) decreasing pain tolerance is also incorrect as Parkinson's does not directly affect pain tolerance. Option D) preventing diarrhea is not a major nursing need in Parkinson's disease unless related to medication side effects, but it is not a primary concern compared to assisting with activities of daily living. In an educational context, understanding the specific nursing needs of patients with neurological conditions like Parkinson's disease is crucial for providing effective and holistic care. Nurses must be skilled in assessing, planning, and implementing care strategies that focus on maintaining patient independence and quality of life while managing the progressive symptoms of the disease. By recognizing and addressing these major nursing needs, nurses can enhance the overall well-being and functional status of patients like Mrs. Moore living with Parkinson's disease.