To attain the goal of ambulation for the patient who is hemiplegic, the initial care plan needs to be structured to first attain

Correct Answer: D

Rationale: In the context of a hemiplegic patient, the correct initial goal for ambulation is the ability to transfer from bed to chair (Option D). This is because successful bed to chair transfers are crucial for promoting independence and mobility in hemiplegic patients. Mastering this skill enhances the patient's ability to perform activities of daily living and is a fundamental step towards eventual ambulation. Option A, acceptance of altered body image, is not the immediate priority for achieving ambulation. While addressing body image concerns is important for overall psychological well-being, it is not directly related to the physical ability to ambulate. Option B, balance training, is essential for safe ambulation, but before focusing on balance, the patient must first demonstrate the ability to transfer from bed to chair effectively. Without this foundational skill, balance training may not be as effective or safe. Option C, adequate energy level, is important for sustaining ambulation efforts, but it is not the initial step in the care plan. Energy levels can be addressed and improved once the patient has successfully mastered bed to chair transfers and is progressing towards ambulation. In an educational context, understanding the sequential and progressive nature of rehabilitation goals in hemiplegic patients is crucial for developing effective care plans. By prioritizing tasks based on their significance and impact on the patient's functional independence, healthcare professionals can optimize outcomes and promote successful rehabilitation.

Correct Answer: A

Rationale: In this scenario, the most appropriate emergency treatment for Mr. Jones, who has a branch lodged in his eye with bleeding eyelid, is to cover the eye with a protective shield (Option A). This action helps to prevent further injury by providing a barrier that can stabilize the foreign object and protect the eye from additional trauma. Option B, encouraging Mr. Jones to hold his eye closed tightly, is incorrect as it may cause further damage by putting pressure on the foreign object. Option C, applying a pressure dressing to the eye, is also inappropriate as it can exacerbate the situation by increasing pressure on the lodged branch and causing more harm. Option D, removing the foreign body and applying a sterile dressing, is not recommended in this situation as removing the object without proper medical equipment and expertise can lead to more severe damage to the eye. Educationally, this question highlights the importance of understanding first aid principles in emergency situations involving eye injuries. It emphasizes the need to prioritize protecting the eye and seeking professional medical help promptly to prevent complications and ensure the best possible outcome for the patient.

Correct Answer: B

Rationale: The correct answer is B) She asks for medication upon the first indication of an attack. This option demonstrates that Mrs. Filbert understands the importance of early intervention in managing her condition effectively. By recognizing the signs of an impending attack and proactively seeking treatment, she shows comprehension of the teaching provided. Option A is incorrect because delaying medication out of fear of addiction is not a recommended approach in managing a medical condition. Option C is incorrect as it does not directly relate to understanding her condition. Option D is also incorrect as asking family for assistance at mealtime does not specifically indicate understanding of her medical condition. In an educational context, it is crucial for patients to demonstrate understanding of their condition by being proactive in managing their health. This includes recognizing symptoms, adhering to treatment plans, and seeking help when needed. By choosing option B, Mrs. Filbert displays a key aspect of patient education and empowerment in managing her health effectively.

Correct Answer: B

Rationale: The correct answer is B) The patient is under the influence of amphetamines. This presentation aligns with amphetamine intoxication, also known as amphetamine use disorder. Amphetamines can cause symptoms such as increased talkativeness, alertness, dilated pupils, elevated temperature, and excessive sweating. These stimulants can also lead to decreased need for sleep, which is consistent with the patient's statement of never needing to sleep anymore. Option A) The patient is under the influence of heroin is incorrect because heroin typically causes symptoms opposite to those described, such as sedation, constricted pupils, and respiratory depression. Option C) The patient is under the influence of oxycodone is incorrect as oxycodone, an opioid, would typically cause symptoms like drowsiness, respiratory depression, and pinpoint pupils. Option D) The patient is under the influence of Oxycodan is not a recognized substance and does not align with any known drug effects. Educationally, it is crucial for healthcare providers to recognize signs of drug intoxication to provide appropriate care and intervention. Understanding the unique effects of different substances can guide treatment decisions and ensure patient safety. This case highlights the importance of thorough assessment and knowledge of substance use manifestations in the medical setting.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) If you are wearing contact lenses, remove them. This is the most appropriate initial action because the symptoms described by the client (redness, itching, increased lacrimation) may indicate an allergic reaction or irritation related to the contact lenses. Removing the contact lenses can help alleviate the symptoms and prevent further irritation or complications. Option A) Please call your doctor, while important, is not the first step in this situation. It is crucial to address the immediate issue before seeking further medical advice. Option B) Apply a cool compress to your eyes may provide some relief but does not address the potential cause of the symptoms. Option D) Taking an over-the-counter antihistamine should not be the first action without first addressing the contact lenses, as the underlying cause may be related to the contacts rather than allergies. From an educational perspective, this question highlights the importance of prioritizing actions based on the presented symptoms. It teaches students to assess the situation, consider potential causes, and implement appropriate interventions in a logical sequence. Understanding the significance of prompt and accurate decision-making in response to patient complaints is essential for effective nursing practice.