What measures can help control the client's body temperature related to brain infection?

Correct Answer: A

Rationale: Controlling body temperature in a client with a brain infection is crucial to prevent complications. The correct answer is A) Administering prescribed antipyretics. Antipyretics help reduce fever by acting on the hypothalamus to lower the body's temperature set point. This is important because high temperatures can worsen brain swelling and increase metabolic demands. Reducing body hydration (Option B) is incorrect because dehydration can lead to further complications in a client with a brain infection. Proper hydration is essential for maintaining cerebral perfusion and overall physiological functions. Applying ice packs (Option C) is not recommended as it can cause vasoconstriction and potentially worsen cerebral blood flow, leading to adverse outcomes in a client with a brain infection. Keeping the room temperature warm (Option D) is also not ideal because it can exacerbate fever in a client with a brain infection. Maintaining a cooler room temperature can help prevent further elevation of body temperature. In an educational context, understanding the rationale behind using antipyretics in controlling body temperature in clients with brain infections is essential for nursing practice. Nurses need to be aware of the implications of fever on neurological conditions and the appropriate interventions to manage it effectively. This knowledge ensures optimal care and positive outcomes for clients with neurological issues.

Correct Answer: D

Rationale: The correct answer to the question is option D, which states, "Be sure to take fluids frequently." This is the most appropriate advice for a client with a neurological deficit related to nutrition and diet for several reasons. Neurological deficits can affect swallowing function, leading to an increased risk of dehydration and aspiration. Encouraging the client to take fluids frequently helps maintain hydration, aids in swallowing, and prevents complications such as aspiration pneumonia. Option A, eating two large meals instead of frequent small meals, is incorrect because it can overload the digestive system, especially for individuals with neurological deficits that may have difficulty with digestion and absorption. Consuming smaller, more frequent meals is generally recommended for better nutrient absorption and energy distribution throughout the day. Option B, consuming a diet low in fiber, is also incorrect. Fiber is essential for digestive health and regular bowel movements. A diet low in fiber can lead to constipation, which can be exacerbated in individuals with neurological deficits who may already have gastrointestinal issues. Option C, chewing foods quickly, is incorrect as well. Clients with neurological deficits may have difficulty with chewing and swallowing, which can increase the risk of choking and aspiration. Chewing food thoroughly and slowly is important to prevent these risks and aid in digestion. In an educational context, it is crucial for nurses to provide tailored nutrition and diet advice to clients with neurological deficits to promote optimal health and prevent complications. Understanding the specific needs and challenges faced by these individuals is essential in developing appropriate dietary recommendations that support their overall well-being. Encouraging frequent fluid intake is a simple yet effective strategy to address hydration and swallowing issues commonly seen in this population.

Correct Answer: C

Rationale: In managing a patient with delirium, it is essential to prioritize the identification and treatment of underlying causes whenever possible. This is the correct answer (Option C) because delirium is often a symptom of an underlying medical issue such as infection, medication side effects, or metabolic disturbances. By addressing the root cause, the delirium can be effectively managed or resolved. Option A, the use of restraints, is inappropriate as it can lead to physical and psychological harm, and should only be considered as a last resort for safety reasons. Option B, the use of short-acting benzodiazepines, can worsen delirium by exacerbating confusion and sedation. Option D, administering high doses of antipsychotic drugs, is not recommended as it can increase the risk of adverse effects in elderly patients and those with underlying neurological conditions. In an educational context, understanding the management of delirium is crucial for healthcare professionals, especially those preparing for exams like the NCLEX. By emphasizing the importance of identifying and addressing underlying causes, students can provide safe and effective care for patients experiencing delirium, promoting better outcomes and quality of life.

Correct Answer: C

Rationale: The correct answer is C: Resolution of spinal shock is manifested by spasticity, hyperreflexia, and reflex emptying of the bladder. This is the most appropriate answer because spinal shock is a temporary condition that occurs immediately after a spinal cord injury and is characterized by a loss of reflexes, flaccid paralysis, and absence of sensation below the level of injury. As the spinal shock resolves, the signs mentioned in option C begin to appear, indicating the return of reflex activity. Option A is incorrect because rehabilitation measures can actually begin during spinal shock to prevent complications and promote optimal recovery. Option B is incorrect because while continuous monitoring for hypotension, tachycardia, and hypoxemia is important in spinal cord injury patients, it is not specific to spinal shock resolution. Option D is incorrect because autonomic functions can be affected in spinal shock, leading to issues such as hypotension and bradycardia. In an educational context, understanding the progression of spinal shock and its resolution is crucial for nurses caring for patients with spinal cord injuries. Recognizing the signs of spinal shock resolution helps in planning appropriate care and interventions to support the patient's recovery and prevent complications. It is essential for nurses to be knowledgeable about neurological assessments, spinal cord injury management, and the implications of spinal shock to provide effective and evidence-based care.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) He may have uncontrolled reflex erections but orgasm and ejaculation are usually not possible. This is because in a male patient with a complete lower motor neuron lesion, there is disruption in the communication between the spinal cord and the brain, leading to impaired voluntary control over sexual function. Reflex erections can still occur due to intact reflex pathways, but the coordination required for ejaculation and orgasm is typically lost. Option A is incorrect because although reflexogenic erections may occur, the ability to achieve orgasm is usually impaired without ejaculation. Option C is incorrect because a complete lower motor neuron lesion would actually affect both psychogenic and reflexogenic erections. Option D is also incorrect as it generalizes the outcome without considering the possibility of reflex erections. In an educational context, it is important for nurses to understand the specific effects of spinal cord lesions on sexual function to provide accurate counseling to patients. By knowing the nuances of how different types of lesions impact sexual responses, nurses can better support patients in managing their expectations and exploring potential interventions to enhance their quality of life.