Nokea
During an interview, the patient states he has the sensation that 'everything around him is spinning.' The nurse recognizes that the portion of the ear responsible for this sensation is the:
- A. Cochlea.
- B. CN VIII.
- C. Organ of Corti.
- D. Labyrinth.
Correct Answer: D
Rationale: The correct answer is D: Labyrinth. The labyrinth is a structure in the inner ear that contains the vestibular system responsible for balance and spatial orientation. The sensation of spinning or vertigo is related to disturbances in the labyrinth. CN VIII, the vestibulocochlear nerve, carries information from the labyrinth to the brain. The cochlea (A) is responsible for hearing, not balance. The Organ of Corti (C) is a structure within the cochlea involved in hearing, not balance. Therefore, the correct choice is D as it directly relates to the sensation of spinning experienced by the patient.
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During which phase of throwing is the elbow joint placed under the most valgus stress?
- A. Follow-through
- B. Wind-up
- C. Early cocking
- D. Late cocking
Correct Answer: D
Rationale: The correct answer is D: Late cocking. During late cocking phase of throwing, the arm is maximally externally rotated which places the elbow joint under the most valgus stress. This is due to the extreme abduction and extension of the arm at this stage, leading to increased valgus force on the elbow joint. In contrast, in the early cocking phase (choice C), the arm is in a more neutral position with less valgus stress. The wind-up phase (choice B) involves more shoulder and trunk movements rather than stressing the elbow joint. Follow-through phase (choice A) comes after the release of the ball and does not involve significant valgus stress on the elbow.
The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?
- A. Osteoarthritis.
- B. Rheumatoid arthritis.
- C. Gout.
- D. Bursitis.
Correct Answer: B
Rationale: The correct answer is B: Rheumatoid arthritis. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.
The nurse is conducting a class on BSE. Which of these statements indicates the proper BSE technique?
- A. The best time to perform BSE is in the middle of the menstrual cycle.
- B. The woman needs to perform BSE only bimonthly unless she has fibrocystic breast tissue.
- C. The best time to perform a BSE is 4 to 7 days after the first day of the menstrual period.
- D. If she suspects that she is pregnant, then the woman should not perform a BSE until her baby is born.
Correct Answer: C
Rationale: The correct answer is C because it states the best time to perform a BSE is 4 to 7 days after the first day of the menstrual period. This timing ensures that the breasts are least likely to be swollen or tender due to hormonal changes, making it easier to detect abnormalities.
A is incorrect because performing BSE in the middle of the menstrual cycle may coincide with hormonal fluctuations that could affect breast tissue. B is incorrect because performing BSE bimonthly may lead to missed changes in the breast. D is incorrect because pregnancy does not preclude a woman from performing BSE; in fact, it is important for pregnant women to monitor their breast health.
The nurse is assessing a patient's skin and notes a raised, rough lesion with a wart-like appearance. What is the most likely diagnosis?
- A. Seborrheic keratosis.
- B. Basal cell carcinoma.
- C. Actinic keratosis.
- D. Squamous cell carcinoma.
Correct Answer: A
Rationale: The correct answer is A: Seborrheic keratosis. This diagnosis is likely due to the lesion's raised, rough, and wart-like appearance, which is characteristic of seborrheic keratosis. Seborrheic keratosis is a common benign skin growth that typically appears in older individuals and presents as brown, black, or tan growths with a waxy, stuck-on appearance. It is important to note that seborrheic keratosis is non-cancerous and does not require immediate medical treatment.
Summary:
- B: Basal cell carcinoma typically presents as a pearly or waxy bump, not a raised, rough lesion with a wart-like appearance.
- C: Actinic keratosis is a precancerous skin condition characterized by rough, scaly patches, not a raised, wart-like lesion.
- D: Squamous cell carcinoma usually appears as a firm red nodule or a flat lesion with a scaly
Which technique is correct when the nurse is assessing the radial pulse of a patient? The pulse is counted for:
- A. 1 minute, if the rhythm is irregular.
- B. 15 seconds and then multiplied by 4, if the rhythm is regular.
- C. 2 full minutes to detect any variation in amplitude.
- D. 10 seconds and then multiplied by 6, if the patient has no history of cardiac abnormalities.
Correct Answer: A
Rationale: The correct technique is to count the radial pulse for 1 minute if the rhythm is irregular because irregular rhythms may have fluctuations that can affect accuracy. Counting for a full minute provides a more comprehensive assessment of the pulse rate.
Choice B is incorrect because multiplying the count by 4 after 15 seconds may not accurately reflect the pulse rate if the rhythm is irregular. Choice C is incorrect because counting for 2 full minutes is unnecessary and can be time-consuming without providing additional benefits in most cases. Choice D is incorrect as multiplying by 6 after 10 seconds is not suitable for irregular rhythms or for patients with cardiac abnormalities.