What is the priority nursing diagnosis for a patient experiencing a migraine headache?

Correct Answer: A

Rationale: The correct answer is option A) Acute Pain related to biologic and chemical factors. The priority nursing diagnosis for a patient experiencing a migraine headache is acute pain because it addresses the immediate and most distressing issue the patient is facing. Migraine headaches are characterized by severe and debilitating pain, making pain management a crucial aspect of care. Option B) Anxiety related to change in or threat to health status may be a secondary nursing diagnosis for a patient with a migraine, but it is not the priority over addressing the acute pain. Option C) Hopelessness related to deteriorating physiological condition is not the priority in this case as migraines, though severe, are typically episodic and not indicative of a deteriorating physiological condition. Option D) Risk for Side Effects related to medical therapy is not the priority nursing diagnosis when the patient is currently experiencing a migraine headache. Managing the acute pain takes precedence over potential side effects of treatment. In an educational context, understanding the priority nursing diagnosis helps students and healthcare professionals prioritize patient care and address the most urgent needs first. By focusing on acute pain management in this case, the nurse can provide timely and effective relief to improve the patient's comfort and overall well-being.

Correct Answer: D

Rationale: In this scenario, the correct observation that the LPN/LVN should report immediately is option D) Shallow respirations and decreased breath sounds. This is crucial because Guillain-Barre Syndrome (GBS) can lead to respiratory muscle weakness, which can progress to respiratory failure and is a life-threatening complication. Option A) Complaints of numbness and tingling are common symptoms of GBS but do not indicate an immediate life-threatening situation. Option B) Facial weakness and difficulty speaking are also signs of GBS but are not as critical as compromised respiratory function. Option C) Rapid heart rate of 102 beats per minute is not uncommon in patients with GBS due to autonomic dysfunction, but it is not as urgent as respiratory distress. Educationally, understanding the priority of assessments in neurological conditions like GBS is crucial for patient safety. Teaching healthcare providers to recognize and respond promptly to respiratory changes can prevent serious complications and improve patient outcomes in neurological emergencies.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for this patient is B) Caregiver Role Strain related to continuous need for providing care. This diagnosis is correct because the husband's statement indicates that he is experiencing strain and stress due to the constant need to monitor and care for his wife, who has Alzheimer's disease and is at risk of wandering during the night. This situation places a significant burden on the caregiver and can lead to physical, emotional, and mental exhaustion. Option A) Decreased Cardiac Output related to poor myocardial contractility is incorrect because there is no direct evidence in the scenario to support this nursing diagnosis. The patient's angina and Alzheimer's disease are not linked to poor myocardial contractility. Option C) Risk for Falls related to patient wandering behavior during the night is incorrect because while the patient's wandering behavior does pose a risk for falls, the focus of the question is on the caregiver's well-being, not solely on the patient's safety. Option D) Ineffective Therapeutic Regimen Management related to poor patient memory is incorrect because the husband's actions do not suggest an issue with the patient's memory affecting her ability to manage her therapeutic regimen. Instead, the scenario highlights the caregiver's struggle in managing the care of a patient with Alzheimer's disease. In an educational context, understanding and identifying caregiver role strain is crucial in providing holistic care to patients with chronic conditions like Alzheimer's disease. Nurses need to assess not only the patient's well-being but also the caregiver's ability to cope with the demands of caregiving. By recognizing and addressing caregiver role strain, healthcare professionals can support both the patient and the caregiver in maintaining their health and well-being.

Correct Answer: B

Rationale: In this scenario, the most appropriate initial collaborative intervention is to transfer the patient to radiology for a CT scan (Option B). This decision is based on the patient's presentation of acute lethargy, confusion, and incontinence following a fall down the stairs, which could suggest a traumatic brain injury or intracranial pathology. A CT scan would help identify any acute intracranial hemorrhage, contusions, or other traumatic brain injuries that may be contributing to the patient's symptoms. Option A, placing the patient on the hospital alcohol withdrawal protocol, is not the initial priority as the patient's symptoms are more indicative of a neurological issue rather than alcohol withdrawal. Option C, inserting a retention catheter, addresses incontinence but does not address the primary concern of the patient's altered mental status. Option D, giving phenytoin, is not indicated as there is no information provided to suggest a need for antiepileptic medication at this time. From an educational perspective, understanding the importance of prioritizing interventions based on the patient's presentation and symptoms is crucial in providing effective care. This case highlights the significance of conducting appropriate diagnostic tests promptly to identify and address potential life-threatening conditions in a timely manner.

Correct Answer: C

Rationale: In the context of autonomic dysreflexia, it is crucial to choose the correct immediate action to prevent serious complications. The correct answer, C) assess for bowel and bladder distention, is the most important initial step when Mr. Jones develops an attack of autonomic dysreflexia. Autonomic dysreflexia is a potentially life-threatening condition characterized by a sudden onset of excessively high blood pressure, triggered by a noxious stimulus below the level of a spinal cord injury. In this scenario, bowel or bladder distention is a common trigger. Assessing for bowel and bladder distention is crucial because addressing the underlying cause can help resolve the autonomic dysreflexia episode. Failure to address this issue promptly can lead to severe consequences such as stroke, seizure, or even death. Now, let's analyze why the other options are incorrect: A) Elevating the head of his bed: While elevating the head of the bed is a standard intervention for managing autonomic dysreflexia once the cause is identified, it is not the most immediate or crucial step in this scenario. B) Monitoring his blood pressure closely: While blood pressure monitoring is essential in managing autonomic dysreflexia, it is not the most critical initial action when an episode occurs. Identifying and addressing the triggering cause should take precedence. D) Encouraging him to ventilate his concerns: While addressing Mr. Jones' concerns is essential for his overall well-being, it is not the most critical action in the acute management of autonomic dysreflexia. Immediate assessment and intervention to address the triggering cause are paramount. In an educational context, understanding the pathophysiology, triggers, and management of autonomic dysreflexia is crucial for healthcare professionals working with patients with spinal cord injuries. By prioritizing the assessment of bowel and bladder distention in this scenario, healthcare providers can effectively manage autonomic dysreflexia episodes and prevent serious complications.