What advice must the nurse give to prevent recurrence of insect bites?

Correct Answer: B

Rationale: The correct answer is B) Apply insect repellant to clothing and exposed skin. Rationale: Insect bites can lead to discomfort, itching, and even potential infections. Applying insect repellant is an effective way to prevent insect bites by creating a barrier between the skin and insects. This advice is crucial to prevent the recurrence of insect bites, especially when individuals are outdoors where they are more likely to encounter insects. Option A) Preventing strenuous exercises by the client when outdoors is not directly related to preventing insect bites. While resting may reduce the likelihood of attracting insects due to sweat and increased body heat, it is not a primary preventive measure against insect bites. Option C) Wearing thick woolen clothing to cover the skin while outdoors may provide some protection against insect bites, but it is not as effective as using insect repellant. Thick clothing may also not be suitable for warm weather or outdoor activities where mobility is important. Option D) Avoiding daily baths to the client with soaps is not a recommended practice for preventing insect bites. Maintaining good hygiene through regular bathing is important for overall skin health but does not directly prevent insect bites. Educational Context: As a nurse, it is essential to educate individuals on preventive measures to safeguard their health. Providing accurate information on how to prevent insect bites is crucial in promoting wellness and preventing potential complications. By understanding the rationale behind each option, nurses can effectively educate patients on the most appropriate strategies to protect themselves from insect bites, ultimately improving patient outcomes.

Correct Answer: A

Rationale: The correct answer is A) Avoid fatigue and take frequent rest periods if needed. This activity-related strategy is crucial for a client with neurological issues going home because fatigue can exacerbate symptoms and hinder recovery. Encouraging rest periods helps conserve energy, prevent overexertion, and promote healing. Option B) Take deep breaths every 4 hours while awake is incorrect as it is not directly related to neurological issues and may not address the client's specific needs. Option C) Make your daily routine rigid so that you can remember what to do is incorrect because flexibility in routines is often more beneficial for neurological clients who may experience cognitive challenges. Option D) Avoid exposure to the outdoors is incorrect unless there are specific environmental triggers that need to be avoided, which is not mentioned in the question stem. In an educational context, it is important for nurses to teach clients practical and individualized strategies to manage their condition at home effectively. Understanding the rationale behind each activity-related strategy is essential for promoting patient compliance and positive outcomes. Teaching clients how to balance activity and rest is a key component of neurological care and can significantly impact their quality of life.

Correct Answer: C

Rationale: In the neurologic assessment of the older adult, the nurse should expect to find decreased sensation of touch and temperature. This is because aging can lead to a decline in sensory perception, including diminished ability to perceive tactile sensations and changes in temperature sensitivity. This can have significant implications for the older adult's safety and quality of life, making it crucial for nurses to assess and address these changes. Option A, absent deep tendon reflexes, is incorrect because while reflexes may diminish with age, they are not typically completely absent in the older adult population. Option B, below-average intelligence score, is not a typical finding in a neurologic assessment of older adults unless there are pre-existing cognitive impairments. Option D, decreased frequency of spontaneous awakening, is more related to sleep patterns and may not necessarily be a direct outcome of a neurologic assessment. Educationally, understanding the expected changes in the neurological system of older adults is essential for nurses caring for this population. It allows for early detection of potential issues, appropriate interventions, and personalized care planning to maintain or improve the older adult's quality of life. By recognizing the normal age-related changes in sensation and cognition, nurses can provide holistic care that addresses the specific needs of older adults in a respectful and effective manner.

Correct Answer: C

Rationale: The correct answer is C) Infarction and necrosis of the cord caused by edema, hemorrhage, and metabolites. In an initial incomplete spinal cord injury, there is already damage to the cord, which leads to a cascade of events such as edema, hemorrhage, and ischemia. This sets off a chain reaction that can worsen the injury and progress it to complete cord damage. Edema and hemorrhage can lead to compression of blood vessels, further reducing blood flow and oxygen to the affected area, causing infarction and necrosis. Option A) Edematous compression of the cord above the level of the injury is incorrect because it does not directly explain why an initial incomplete injury progresses to complete cord damage. Option B) Continued trauma to the cord resulting from damage to stabilizing ligaments is incorrect because it focuses on external factors rather than the internal processes that lead to complete cord damage. Option D) Mechanical transection of the cord by sharp vertebral bone fragments after the initial injury is incorrect because it describes a different mechanism of injury, rather than the progression from incomplete to complete cord damage. Educationally, understanding the pathophysiology of spinal cord injuries is crucial for nurses preparing for the NCLEX exam. Knowing how secondary damage occurs and leads to worsening conditions is essential for providing optimal care to patients with spinal cord injuries. This knowledge helps nurses anticipate complications and intervene promptly to prevent further damage.

Correct Answer: C

Rationale: In this scenario, the most helpful teaching for a patient with paraplegia and an irritable bladder with reflex emptying is option C: To empty the bladder with manual pelvic pressure in coordination with reflex voiding patterns. This technique, known as Crede maneuver, involves applying manual pressure on the lower abdomen to assist in bladder emptying by utilizing the existing reflex voiding mechanism. Option A (Hygiene care for an indwelling urinary catheter) is incorrect because using a catheter is not the ideal long-term solution for a patient with reflex emptying bladder due to the risk of infections and complications associated with catheterization. Option B (How to perform intermittent self-catheterization) is also not the best choice as in this case, the patient is experiencing reflex emptying, and self-catheterization may not address the specific issue of irritable bladder with reflex emptying effectively. Option D (That a urinary diversion, such as an ileal conduit, is the easiest way to handle urinary elimination) is not appropriate for this patient because urinary diversions are usually considered when other interventions have failed, and they are more invasive procedures that are not typically the first line of management for reflex emptying bladder. From an educational perspective, teaching the patient how to coordinate manual pelvic pressure with reflex voiding patterns empowers the patient to actively participate in managing their bladder function effectively, promoting independence, and potentially reducing the need for invasive interventions. This approach aligns with patient-centered care and encourages patient engagement in self-care management.