Which patient should the nurse assess first after change-of-shift report?

Correct Answer: C

Rationale: In this scenario, the nurse should assess the 28-year-old patient with a fracture complaining that the cast is tight first after change-of-shift report. This patient requires immediate attention because a tight cast can lead to complications such as compromised circulation, nerve damage, and increased pain. Addressing this issue promptly is crucial to prevent further harm and ensure the patient's safety and comfort. Option A: The 42-year-old patient with carpal tunnel syndrome complaining of pain can be assessed after addressing the urgent situation with the patient whose cast is tight. While pain management is important, it is not an immediate threat to the patient's well-being in the same way that a tight cast can be. Option B: The 64-year-old patient with osteoporosis waiting for discharge is not a priority over the patient with a tight cast. Discharge planning can be addressed once the urgent patient needs are met. Option D: The 56-year-old patient with left leg amputation complaining of phantom pain also requires attention, but phantom pain, while distressing, is not a critical issue that necessitates immediate intervention to prevent physical harm like the tight cast does. Educational Context: This question assesses the nurse's ability to prioritize patient care based on the urgency of the situation. Understanding the potential complications of a tight cast and the importance of assessing and addressing it promptly is essential in providing safe and effective nursing care. By choosing the correct answer, nurses learn to prioritize patient needs to ensure the best outcomes for those under their care.

Correct Answer: B

Rationale: In the case of a client diagnosed with encephalitis, the most critical nursing intervention is option B: Observing closely for signs of respiratory distress. Encephalitis is an inflammation of the brain that can lead to serious complications, including respiratory compromise. Monitoring for signs of respiratory distress such as increased respiratory rate, use of accessory muscles, cyanosis, and changes in oxygen saturation is crucial for early detection and intervention to prevent respiratory failure. Option A, evaluating ventilation capacity and lung sounds, is important but not as critical as monitoring for respiratory distress in this scenario. Encephalitis primarily affects the brain, so focusing on respiratory distress takes precedence over routine assessment of lung sounds. Option C, administering an indwelling urethral catheter, is not directly related to the priority issue of respiratory distress in a client with encephalitis. While urinary elimination is important, it is not the most critical concern in this situation. Option D, monitoring vital signs and level of consciousness (LOC) frequently, is a general nursing intervention that is important in many situations, including encephalitis. However, in this case, monitoring specifically for signs of respiratory distress takes precedence over general vital sign assessment due to the potential for rapid deterioration in respiratory status. Educationally, it is important for nurses to understand the prioritization of interventions based on the client's condition. This rationale highlights the critical thinking process involved in determining the most urgent nursing intervention for a specific diagnosis like encephalitis. Nurses must be able to quickly identify and respond to the most pressing issues to ensure optimal patient outcomes.

Correct Answer: C

Rationale: The most appropriate nursing instruction to manage a young male client with chronic tension headaches is option C) Counseling on alternate therapies. This is the correct answer because chronic tension headaches often have a strong connection to stress and muscle tension. By counseling the client on alternate therapies such as relaxation techniques, mindfulness, acupuncture, or massage therapy, the nurse can address the root cause of the headaches and provide non-pharmacological methods for managing pain and stress. Option A) Instructing the client to monitor for signs of bruising or bleeding is incorrect as it is not relevant to tension headaches. Option B) Suggesting eating and swallowing techniques that reduce the potential for aspiration is also incorrect as it is more related to dysphagia, not tension headaches. Option D) Advising the client to change sleeping positions frequently may help with other conditions like neck pain but is not directly related to managing tension headaches. In an educational context, it is important for nurses to understand the underlying causes of common health issues like tension headaches and to be able to provide holistic care that includes both pharmacological and non-pharmacological interventions. Counseling on alternate therapies empowers the client to take an active role in managing their health and promotes a more comprehensive approach to healthcare.

Correct Answer: B

Rationale: In the management of ischemic stroke, the administration of tissue plasminogen activator (TPA) is crucial in improving outcomes. The correct answer is B) 3 hours. This is because TPA is most effective when given within the first 3 hours of symptom onset. Administering TPA within this time frame can help dissolve the blood clot causing the ischemic stroke and restore blood flow to the affected area of the brain, minimizing long-term damage. Option A) 6 hours is incorrect because waiting this long reduces the efficacy of TPA and increases the risk of complications. Option C) 8 hours and Option D) 10 hours are even further beyond the optimal window for TPA administration, significantly decreasing its effectiveness. Educationally, understanding the time-sensitive nature of TPA administration emphasizes the importance of rapid assessment, diagnosis, and treatment in stroke care. This knowledge underscores the critical role of healthcare providers in recognizing and responding promptly to stroke symptoms to maximize the chances of a positive outcome for the patient.

Correct Answer: B

Rationale: In the context of a client with a neurological disorder, the correct nursing intervention to reduce hemostasis and decrease the potential for thrombophlebitis is option B) Change the client's position. Explanation of why option B is correct: 1. Prolonged immobility in clients with neurological disorders can lead to decreased circulation, increasing the risk of blood clots and thrombophlebitis. Changing the client's position regularly helps promote circulation and prevents stasis of blood in the extremities. 2. Position changes also help in preventing pressure ulcers, improving respiratory function, and maintaining musculoskeletal integrity in clients with neurological issues. Explanation of why the other options are incorrect: 1. Option A) Remove and reapply elastic stockings: While elastic stockings may aid in preventing deep vein thrombosis (DVT), in the context of neurological disorders, changing the client's position is more effective in promoting circulation. 2. Option C) Keep extremities at neutral position: While keeping extremities at a neutral position is important for preventing contractures and maintaining proper alignment, it does not directly address the issue of reducing hemostasis and thrombophlebitis in this scenario. 3. Option D) Use a flotation mattress: While flotation mattresses can help redistribute pressure and prevent pressure ulcers, they do not directly address the issue of promoting circulation and reducing the risk of thrombophlebitis in clients with neurological disorders. Educational Context: Understanding the rationale behind selecting the appropriate nursing intervention is crucial for nurses caring for clients with neurological disorders. Regular position changes not only help in preventing complications like thrombophlebitis but also promote overall patient comfort, circulation, and skin integrity. Nurses should be aware of the specific needs of clients with neurological disorders and be proactive in implementing appropriate interventions to prevent complications associated with immobility.