Which of these patients in the neurologic ICU will be best to assign to an RN who has floated from the medical unit?

Correct Answer: C

Rationale: The correct answer to the question is option C, the 46-year-old patient admitted 48 hours ago with bacterial meningitis and has an antibiotic dose due. This patient is the best choice for the RN from the medical unit because bacterial meningitis requires close monitoring, timely administration of antibiotics, and ongoing assessment for any changes in neurological status. The RN from the medical unit would likely have more experience and comfort managing infectious conditions and administering antibiotics compared to the other neurologically complex cases presented in the question. Option A, the 26-year-old patient with a basilar skull fracture and clear drainage coming out of the nose, requires specialized neurologic care due to the risk of cerebrospinal fluid leak and potential complications. Option B, the 42-year-old patient with a ruptured berry aneurysm, also needs specialized care in a neuro ICU setting for monitoring and potential interventions related to the aneurysm. Option D, the 65-year-old patient with an astrocytoma who just had a craniotomy, requires specialized neurosurgical care and monitoring postoperatively. Providing this educational context helps students understand the importance of matching the complexity and acuity of patients with the appropriate level of nursing expertise to ensure safe and effective care delivery, especially in critical care settings like the neurologic ICU.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) lack of muscle activity results in poor circulation. Turning a patient every 2 hours is a crucial preventive measure to avoid developing decubitus ulcers or pressure sores. When a patient is immobile or paralyzed, the lack of movement can lead to pressure on certain areas of the body, reducing circulation to those areas. This restricted blood flow can cause tissue damage, leading to the formation of ulcers. Option A is incorrect because while nutritional requirements may be increased in paralyzed patients, it is not the primary reason for developing decubitus ulcers. Option B is incorrect as muscle spasms causing flexion contractures may contribute to the risk of pressure sores, but it is not the primary reason for their development. Option C is also incorrect as retention of waste products causing metabolic acidosis is not directly linked to the formation of decubitus ulcers. Educationally, understanding the rationale behind turning immobile patients helps students grasp the importance of preventive nursing care. It reinforces the significance of maintaining proper circulation to prevent complications such as pressure ulcers, highlighting the holistic care approach needed for patients with limited mobility. This knowledge is vital for nurses to provide effective care and prevent potential complications in their patients.

Correct Answer: D

Rationale: The correct answer is D) ability to transfer from bed to chair. In the context of a hemiplegic patient, the ability to transfer from bed to chair is a crucial initial step in achieving the goal of ambulation. This skill is essential as it directly impacts the patient's functional independence and mobility. Mastering the transfer from bed to chair requires the patient to engage and coordinate various muscle groups, improve balance, and enhance overall strength. It serves as a foundational skill that sets the stage for more advanced mobility tasks like walking. Option A) acceptance of his altered body image may be an important psychological aspect of the patient's overall well-being, but it is not the immediate priority in achieving ambulation. Option B) balance training is important in the rehabilitation process, but without the ability to transfer from bed to chair, the patient would not be able to progress to more advanced training. Option C) adequate energy level is necessary for participation in therapy sessions and activities, but it is not the primary factor in achieving ambulation for a hemiplegic patient. In an educational context, understanding the hierarchy of goals in the care plan for a hemiplegic patient is crucial for healthcare professionals to provide effective rehabilitation. By prioritizing tasks such as mastering transfers, healthcare providers can ensure a systematic and goal-oriented approach to rehabilitation that maximizes the patient's potential for recovery and independence.

Correct Answer: C

Rationale: In the case of Mrs. Iris, who is likely experiencing some form of neurological impairment, it is crucial to focus on exercises that target specific muscle groups to maintain or improve her range of motion and prevent contractures. Option C, gluteal muscle-setting exercises, is the most important for her right leg because these exercises help to strengthen the gluteal muscles, which play a significant role in hip stability and mobility. Strengthening these muscles can aid Mrs. Iris in maintaining proper alignment and function of her right leg during daily activities. Options A and B, adduction of the leg and 45° knee flexion and extension exercises, while important for overall lower limb mobility, may not be as critical for Mrs. Iris at this stage. Adduction exercises involve moving the leg toward the midline of the body, which may not directly address her specific needs related to gluteal muscle weakness. Knee flexion and extension exercises are beneficial but do not target the gluteal muscles, which are particularly important for Mrs. Iris's stability and gait. Option D, dorsiflexion and plantar flexion of the foot, primarily target the muscles in the lower leg and foot, which are important for gait and balance. While these exercises are valuable, they do not directly address the weakness in Mrs. Iris's gluteal muscles, which are crucial for her right leg function. In an educational context, understanding the rationale behind selecting specific exercises for patients with neurological impairments is essential for nurses and healthcare professionals. By focusing on muscle-setting exercises that target specific muscle groups, like the gluteals in this case, healthcare providers can tailor rehabilitation programs to address individual patient needs effectively. This approach ensures that interventions are evidence-based and patient-centered, leading to better outcomes for patients like Mrs. Iris.

Correct Answer: B

Rationale: In this scenario, the correct initial aspect to evaluate is the balance between exercise and rest (Option B). This is because increasing joint pain and stiffness could be related to overexertion or inadequate rest periods, especially considering the patient's neurological condition. It is crucial to assess if Mrs. Rollo is engaging in appropriate levels of physical activity and allowing for sufficient rest to prevent exacerbation of her symptoms. Option A (Diet) may be important for overall health, but in this case, joint pain and stiffness are more likely related to physical activity and rest. Option C (Use of fad diet or appliances) is not directly relevant to the symptoms described. Option D (Feelings of self-worth and self-concept) is important in a holistic assessment but is not the priority when addressing physical symptoms like joint pain and stiffness in this context. From an educational perspective, this question highlights the importance of considering lifestyle factors in assessing and managing patient symptoms, especially in individuals with neurological conditions. It emphasizes the need for a comprehensive approach to care that takes into account the interconnectedness of physical and mental well-being. This rationale reinforces the significance of critical thinking and prioritization in nursing practice, particularly in community health settings where holistic care is essential.