Which of the following activity-related strategies would a nurse teach a client who is going home?

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: 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.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Compare the muscle mass of one leg with the other. When a nurse observes a gait disturbance in a patient, it can indicate a potential neurological or musculoskeletal issue. Comparing the muscle mass of one leg with the other can help identify any asymmetry or muscle atrophy, which could be indicative of neurological conditions, such as stroke, spinal cord injury, or peripheral nerve damage. Option A) Palpate the hips for crepitation is incorrect because crepitation refers to a crackling or grating sound or sensation, typically felt on movement of the joints. While crepitation can be a sign of certain musculoskeletal conditions, it is not directly related to evaluating a gait disturbance in this context. Option B) Measure the length of the limbs is incorrect as limb length discrepancy is more related to orthopedic issues and typically would not be the primary assessment when evaluating a gait disturbance. Option C) Evaluate the degree of leg movement is incorrect because while assessing leg movement is important in a comprehensive neurological assessment, it may not directly help in identifying the underlying cause of a gait disturbance related to muscle asymmetry or atrophy. In an educational context, understanding how to assess and interpret gait disturbances is crucial for nurses caring for patients with neurological conditions. By knowing the significance of comparing muscle mass between legs, nurses can provide more targeted care and collaborate effectively with the healthcare team to develop appropriate interventions and treatment plans.

Correct Answer: C

Rationale: In this scenario, option C is correct because bursitis is the inflammation of the synovial membrane sac at friction sites, which are small, fluid-filled sacs that reduce friction between bones, tendons, and muscles near joints. When these sacs become inflamed, it causes pain, swelling, and tenderness in the affected area. This is a common condition among athletes due to repetitive movements or overuse of a joint. Option A, tearing of a ligament, is incorrect because bursitis does not involve damage to ligaments. Option B, stretching of muscle and fascia sheath, is incorrect as bursitis primarily affects the synovial membrane sac, not muscles or fascia. Option D, incomplete separation of articular surfaces of joint caused by ligament injury, is also incorrect as it describes a different condition involving joint surfaces, not bursitis. Understanding the pathophysiology of bursitis is crucial for nurses to accurately assess, diagnose, and provide appropriate care for patients presenting with this condition. By knowing the specific tissue involved and the typical symptoms associated with bursitis, nurses can effectively educate patients on self-care strategies, management of symptoms, and prevention of further injuries.