You are preparing a nursing care plan for the patient with SCI including the nursing diagnoses Impaired Physical Mobility and Self-Care Deficit. The patient tells you, 'I don't know why we're doing all this. My life's over.' What additional nursing diagnosis takes priority based on this statement?

Correct Answer: C

Rationale: The correct answer is C) Impaired Adjustment to Spinal Cord Injury. This nursing diagnosis takes priority based on the patient's statement indicating feelings of hopelessness and a sense of life being over. Addressing the patient's emotional response to the SCI is crucial for their overall well-being and successful rehabilitation. Option A) Risk for Injury related to altered mobility is not the priority in this case as the patient's emotional distress is more urgent to address. Option B) Imbalanced Nutrition, Less Than Body Requirements may be a concern but is not the priority when the patient is expressing significant emotional distress. Option D) Poor Body Image related to immobilization is also important to address but does not take precedence over addressing the patient's emotional adjustment to the SCI. In an educational context, it is important for nurses to recognize and prioritize nursing diagnoses based on the patient's expressed emotions and psychological well-being. Addressing emotional needs can have a significant impact on the patient's overall recovery and quality of life following a spinal cord injury.

Correct Answer: D

Rationale: Autonomic dysreflexia is a sudden, potentially life-threatening condition that can occur in individuals with spinal cord injuries above the T6 level. The correct answer, option D, "sudden exaggerated sympathetic discharge," accurately describes autonomic dysreflexia. When a noxious stimulus triggers this condition, there is an abrupt increase in sympathetic activity leading to severe hypertension, bradycardia, pounding headache, and profuse sweating. Option A is incorrect because autonomic dysreflexia typically occurs in patients with cord damage above T6, not below. Option B is incorrect as autonomic dysreflexia does not directly cause cerebral hemorrhage or myocardial infarction but can lead to other serious complications if not promptly managed. Option C is incorrect as autonomic dysreflexia is not a normal sequelae of spinal cord injury; it is a medical emergency requiring immediate attention. In an educational context, understanding autonomic dysreflexia is crucial for healthcare providers working with patients who have spinal cord injuries. Recognizing the signs and symptoms, as well as knowing how to intervene promptly, can prevent serious complications and save lives. Educating healthcare professionals on the management of autonomic dysreflexia is essential for ensuring the safety and well-being of individuals with spinal cord injuries.

Correct Answer: B

Rationale: In caring for a client with Parkinson's disease, it is most important to choose option B) explain the nature and treatment of the disease. This is because education plays a crucial role in empowering individuals with Parkinson's disease to actively participate in managing their condition. Providing information about the disease helps the client understand the symptoms, progression, available treatments, and potential complications, enabling them to make informed decisions about their care. Option A) encouraging a low-residue diet is not the most important intervention for Parkinson's disease. While diet may play a role in overall health, it is not the priority when addressing the specific needs of a client with this condition. Option C) restricting fluid intake is not a recommended intervention for Parkinson's disease unless specifically indicated due to another medical condition. Hydration is generally important for overall health, and restrictions should be based on individual needs and medical reasons. Option D) providing a walker for ambulation may be beneficial for some clients with Parkinson's disease to assist with mobility, but it is not the most critical intervention compared to educating the client about the disease itself. Education about Parkinson's disease takes precedence in empowering the client to understand and manage their condition effectively. In an educational context, understanding the rationale behind prioritizing education for individuals with Parkinson's disease emphasizes the importance of patient-centered care and promoting autonomy in managing their health. By providing comprehensive information about the disease, healthcare professionals support clients in making informed decisions and actively participating in their care, ultimately improving health outcomes and quality of life.

Correct Answer: A

Rationale: The correct answer is A) keeping frequently used objects on his left side. This strategy is essential for safety self-promotion because individuals with right homonymous hemianopia have a visual field deficit on the right side, making it difficult for them to see objects placed in that visual field. By keeping objects on the left side, the patient can easily access and interact with them without having to strain or potentially injure themselves by reaching into their blind visual field. Option B) asking visitors to approach from the affected side is incorrect because it does not address the patient's safety in daily activities and may not always be feasible in all situations. Option C) frequently checking the position of affected extremities in space is not directly related to safety self-promotion in this scenario and may not be necessary for this specific patient. Option D) adhering to one-handed activities is not the most practical or efficient way for the patient to ensure safety and independence in daily life. In an educational context, this question highlights the importance of understanding how specific neurological deficits can impact a patient's safety and independence in performing daily activities. It emphasizes the need for healthcare providers to educate patients on practical strategies to promote safety and autonomy while living with neurological impairments. By choosing the correct answer, healthcare professionals can help patients effectively manage their condition and navigate their environment with greater confidence and reduced risk of injury.

Correct Answer: C

Rationale: The correct answer is C) Elevate the foot of the entire bed. This nursing measure is appropriate to relieve pressure in the ischial area caused by the Thomas half-ring. Elevating the foot of the bed helps redistribute the patient's weight, reducing pressure on the ischial area where the Thomas half-ring is placed. This position helps in promoting blood flow and preventing pressure ulcers. Option A) Wash, dry, and powder the skin well is incorrect because while maintaining skin hygiene is important for overall skin health, it would not directly address the pressure in the ischial area. Option B) Increasing the weight on the rope suspending the ring is incorrect as it would exacerbate the pressure on the ischial area, causing more discomfort and potential harm to the patient. Option D) Raising the head to semi-Fowler position is incorrect as it would not effectively alleviate pressure on the ischial area. This position is more commonly used for respiratory or cardiac issues, not for relieving pressure in the ischial area. In an educational context, it is crucial for nursing students to understand the importance of proper positioning and pressure relief techniques in preventing complications such as pressure ulcers. By selecting the appropriate nursing measure, students can enhance their clinical reasoning skills and provide effective care to patients with positioning-related issues.