Which patient should be assigned to the traveling nurse, new to neurologic nursing care, who has been on the neurologic unit for 1 week?

Correct Answer: A

Rationale: The correct answer is A) A 34-year-old patient newly diagnosed with multiple sclerosis (MS). This patient is the most suitable for assignment to the traveling nurse new to neurologic nursing care due to several reasons. Firstly, a newly diagnosed MS patient would likely not have complex care needs compared to patients with chronic conditions like ALS or GBS in respiratory distress. This would provide a good learning opportunity for the new nurse to gain confidence and skills in managing neurologic conditions. Additionally, as a newly diagnosed patient, there may be a focus on education, symptom management, and emotional support, which aligns well with the new nurse's learning objectives. Option B) The 68-year-old patient with chronic amyotrophic lateral sclerosis (ALS) may have complex care needs and require specialized care due to the progressive nature of the disease. The new nurse may not have the experience or skills yet to effectively manage the care needs of a patient with ALS. Option C) The 56-year-old patient with Guillain-Barré syndrome (GBS) in respiratory distress requires urgent and specialized care, including respiratory support. This patient's condition is critical and may be overwhelming for a nurse who is new to neurologic nursing care. Option D) The 25-year-old patient admitted with C4 level spinal cord injury (SCI) may also have complex care needs, including potential respiratory issues and neurologic deficits. This patient would require a nurse with more experience in neurologic nursing care to provide comprehensive and safe management. Assigning the newly diagnosed MS patient to the traveling nurse would offer a suitable learning experience while ensuring safe and appropriate care for the patient. This scenario provides a balance between the patient's needs and the nurse's learning requirements, fostering professional growth and quality patient care.

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.

Correct Answer: C

Rationale: Rationale: The correct answer is C) Restricting fluid intake for 12 hours after a myelogram procedure. This restriction is necessary to prevent the risk of developing a post-procedure headache known as a "spinal headache." When contrast dye is injected into the spinal canal during a myelogram, there is a risk of a leak of cerebrospinal fluid (CSF) from the puncture site, which can lead to a headache if the body's fluid levels are not properly maintained. By restricting fluid intake, the body can help replenish the lost CSF and reduce the likelihood of developing a headache. Option A) Watching him for a possible sensitivity reaction is incorrect because it is a standard procedure to monitor patients for any allergic reactions after a myelogram due to the contrast dye used. Option B) Elevating his head and thorax 15-30° for 8 hours is incorrect as this position is typically recommended post-myelogram to help reduce the risk of CSF leakage and subsequent headache. Option D) Administering aspirin for headache is incorrect because aspirin or other non-steroidal anti-inflammatory drugs (NSAIDs) should be avoided post-myelogram as they can increase the risk of bleeding due to their blood-thinning effects. Educational Context: Understanding the post-procedure care and potential complications following a myelogram is crucial for healthcare professionals to ensure patient safety and optimal recovery. By knowing the rationale behind each aspect of care, professionals can provide informed and effective support to patients undergoing such procedures. It is essential to follow the specific guidelines and recommendations to prevent adverse outcomes and promote the best possible patient outcomes.