To which patient would you assign the nurse pulled from the PACU for the day?

Correct Answer: D

Rationale: The correct answer is D) A 72-year-old patient with Paget's disease who has just returned from surgery for total knee replacement. The rationale behind this choice is that this patient requires specialized care and attention post-surgery due to the complexity of the procedure and the underlying Paget's disease, which can affect bone health and healing. The nurse pulled from the PACU, with experience in post-operative care and monitoring, is best suited to provide the necessary support and monitoring for this patient. Option A is incorrect because teaching prior to hyperbaric oxygen therapy for osteomyelitis does not require immediate post-operative care expertise. Option B is incorrect as the patient with osteomalacia being discharged to a long-term care facility would benefit more from a nurse specializing in long-term care transitions. Option C is incorrect as assessing knowledge of orthotic device use in a patient with osteoporosis does not require the expertise of a nurse from the PACU. In an educational context, this question highlights the importance of matching nursing expertise with patient needs based on their specific conditions and care requirements. Understanding the role of nurses in different specialties and settings is crucial for providing optimal patient care and ensuring positive outcomes.

Correct Answer: C

Rationale: The correct answer is C) Positive Kernig's sign. Kernig's sign is a physical examination finding indicative of meningeal irritation, commonly seen in meningitis. When a client with meningitis has Kernig's sign, they will experience pain and resistance to leg extension when the thigh is flexed at the hip. This is due to inflammation of the meninges, causing irritation of the nerve roots in the spine. A) Opisthotonos is a severe condition characterized by the client's back and neck arching in a rigid manner, typically seen in severe cases of meningitis, but it does not specifically relate to the described leg extension test. B) Brudzinski's sign is another physical exam finding associated with meningitis, where neck flexion causes involuntary flexion of the hips and knees. While related to meningitis, it does not involve the specific leg extension test described in the question. D) Nuchal rigidity refers to stiffness and pain in the neck when trying to flex the neck forward, commonly seen in meningitis due to meningeal irritation. However, it does not involve the leg extension test described in the question. Educationally, understanding the specific physical exam findings associated with meningitis, such as Kernig's sign, Brudzinski's sign, and nuchal rigidity, is crucial for healthcare providers to promptly recognize and diagnose this serious condition. Recognition of these signs can lead to early intervention and treatment, potentially preventing severe complications and improving patient outcomes.

Correct Answer: A

Rationale: In the case of a client with a head injury from being thrown off a motorcycle, the most appropriate nursing intervention is option A: Assess LOC every hour or more often if needed. This is the correct answer because monitoring the client's level of consciousness is crucial in identifying any deterioration or changes in neurological status, which can indicate worsening injury or complications. Regular assessment allows for prompt intervention and prevents potential adverse outcomes. Option B, putting the code cart outside the client's room, is incorrect as it is not a priority intervention for a head injury. A code cart is usually used for medical emergencies like cardiac arrest and is not directly related to the immediate care of a head injury patient. Option C, keeping the client quiet in bed, is also incorrect. While minimizing stimuli and maintaining a calm environment is important for head injury patients, it is not the most critical intervention compared to assessing LOC. Option D, allowing one visitor at a time, is not the most appropriate intervention for a client with a head injury. While visitor restrictions may be necessary in certain cases, it is not the priority in the immediate care of a client with a head injury. In an educational context, it is essential for nursing students to understand the priority interventions for clients with head injuries to provide safe and effective care. Assessing LOC is a fundamental skill in neurological assessment and plays a crucial role in identifying changes that may require immediate intervention. This rationale highlights the importance of prioritizing interventions based on the client's condition and the potential impact on their health outcomes.

Correct Answer: A

Rationale: In understanding the differences between lesions in lower motor neurons (LMN) and upper motor neurons (UMN), it is crucial to grasp their distinct effects on neurological function. Option A, "Causes hyporeflexia and flaccidity," is the correct answer. When a lesion occurs in an LMN, it leads to hyporeflexia (reduced reflexes) and flaccidity (loss of muscle tone) due to the disruption of signals from the LMN to the muscles. This results in weakness and muscle atrophy in the affected area. Conversely, lesions in UMN, as seen in options B, C, and D, have different implications. Option B is incorrect because UMN lesions affect motor control of both upper and lower body, not just the lower body. Option C is incorrect because UMN lesions arise in structures above the spinal cord, including the brain's cortex and brainstem, not specifically above the spinal cord. Option D is incorrect as UMN lesions do not interfere with reflex arcs in the spinal cord; instead, they disrupt voluntary motor functions. Educationally, understanding the distinction between LMN and UMN lesions is vital in clinical practice. Recognizing the specific characteristics of each type of lesion aids healthcare professionals in localizing the injury and determining appropriate treatment strategies. This knowledge is fundamental for diagnosing conditions like spinal cord injuries, strokes, and neurodegenerative diseases accurately.

Correct Answer: C

Rationale: In caring for a patient experiencing an acute attack of trigeminal neuralgia, maintaining a quiet, comfortable, draft-free environment (option C) is crucial. Trigeminal neuralgia is a condition characterized by severe facial pain, often triggered by touch or movement, so a calm environment helps reduce stimuli that may exacerbate the pain. Option A, carrying out all hygiene and oral care, may worsen the pain as any touch to the face can trigger excruciating discomfort in patients with trigeminal neuralgia. Option B, using conversation to distract the patient, may not be effective as talking or movement around the patient can inadvertently increase pain. Option D, having the patient examine the mouth for residual food, is not a priority during an acute attack and may even worsen the pain due to movement. Educationally, understanding the specific care needs of patients with trigeminal neuralgia highlights the importance of creating a therapeutic environment that minimizes stimuli that can trigger pain. Nurses must prioritize pain management strategies that promote comfort and reduce sensory input to provide optimal care for patients with neurological conditions like trigeminal neuralgia.