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Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?
- A. The malleus can be visualized during otoscopic examination.
- B. The tympanic membrane is pearly gray.
- C. Tenderness is reported by the patient when the mastoid area is palpated.
- D. Clear, watery fluid is draining from the patients ear.
Correct Answer: D
Rationale: Correct Answer: D
Rationale:
1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis.
2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents.
3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications.
Summary:
A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario.
B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident.
C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.
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A nurse preceptor is working with a student nurse.Which behavior by the student nurse will require the nurse preceptor to intervene?
- A. Chew gum
- B. Turn off the television.
- C. Speak clearly and loudly
- D. Use at least 14-point print
Correct Answer: B
Rationale: The correct answer is B because turning off the television is necessary for effective learning and communication between the nurse preceptor and student nurse. Watching TV can be distracting and disrespectful during the learning process. Choices A, C, and D are incorrect because chewing gum, speaking clearly and loudly, and using at least 14-point print are behaviors that do not hinder the learning process and can be acceptable in a professional setting.
The nurse is reviewing the physicians notes from the patient who has just left the clinic. The nurse learns that the physician suspects a malignant breast tumor. On palpation, the mass most likely had what characteristic?
- A. Nontenderness
- B. A size of 5 mm
- C. Softness and a regular shape
- D. Mobility
Correct Answer: D
Rationale: The correct answer is D: Mobility. A malignant breast tumor typically lacks mobility due to its fixed attachment to surrounding tissues. This characteristic is concerning for malignancy as it suggests invasive growth.
Incorrect answers:
A: Nontenderness - Tenderness does not reliably indicate malignancy or benignancy.
B: A size of 5 mm - Tumor size alone does not determine malignancy.
C: Softness and a regular shape - Malignant tumors are often firm and irregular in shape.
A patient diagnosed with arthritis has been taking aspirin and now reports experiencing tinnitus and hearing loss. What should the nurse teach this patient?
- A. The hearing loss will likely resolve with time after the drug is discontinued.
- B. The patients hearing loss and tinnitus are irreversible at this point.
- C. The patients tinnitus is likely multifactorial, and not directly related to aspirin use.
- D. The patients tinnitus will abate as tolerance to aspirin develops.
Correct Answer: B
Rationale: The correct answer is B because hearing loss and tinnitus caused by aspirin are typically irreversible. Aspirin is known to cause ototoxicity, which can lead to permanent damage to the auditory system. The nurse should inform the patient that the hearing loss and tinnitus may not improve even after discontinuing aspirin.
Choice A is incorrect because hearing loss caused by aspirin is usually permanent. Choice C is incorrect because aspirin is a known cause of tinnitus and hearing loss. Choice D is incorrect because tolerance to aspirin does not prevent or reverse ototoxic effects like tinnitus and hearing loss.
The nurse is creating a care plan for a patient suffering from allergic rhinitis. Which of the following outcomes should the nurse identify?
- A. Appropriate use of prophylactic antibiotics
- B. Safe injection of corticosteroids
- C. Improved skin integrity
- D. Improved coping with lifestyle modifications
Correct Answer: D
Rationale: The correct answer is D: Improved coping with lifestyle modifications. This outcome is appropriate for a patient with allergic rhinitis as it focuses on helping the patient manage the condition through lifestyle changes, such as avoiding allergens and using medications as prescribed. By improving coping skills, the patient can better manage symptoms and reduce the impact of allergic rhinitis on daily life.
Rationale:
1. A: Appropriate use of prophylactic antibiotics is not relevant for allergic rhinitis, which is not typically treated with antibiotics.
2. B: Safe injection of corticosteroids is not a primary treatment for allergic rhinitis and may not be necessary for all patients.
3. C: Improved skin integrity is not a priority outcome for allergic rhinitis, as it primarily affects the respiratory system, not the skin.
Summary:
Improving coping with lifestyle modifications is the most relevant outcome for a patient with allergic rhinitis, as it addresses the management of symptoms and overall quality of
A 55-year-old man presents at the clinic complaining of erectile dysfunction. The patient has a history of diabetes. The physician orders tadalafil (Cialis) to be taken 1 hour before sexual intercourse. The nurse reviews the patients history prior to instructing the patient on the use of this medication. What disorder will contraindicate the use of tadalafil (Cialis)?
- A. Cataracts
- B. Retinopathy
- C. Hypotension
- D. Diabetic nephropathy
Correct Answer: B
Rationale: The correct answer is B: Retinopathy. Tadalafil (Cialis) is contraindicated in patients with retinopathy due to the potential risk of worsening vision problems. Retinopathy is a serious eye condition commonly associated with diabetes, and using tadalafil can lead to further complications in the eyes. It is crucial for patients with retinopathy to avoid medications that can exacerbate their eye condition.
Incorrect choices:
A: Cataracts - Cataracts do not contraindicate the use of tadalafil. Tadalafil does not have a direct negative impact on cataracts.
C: Hypotension - Hypotension is not a contraindication for tadalafil use. In fact, tadalafil can cause a drop in blood pressure, so it should be used with caution in patients with hypotension.
D: Diabetic nephropathy - Diabetic nephropathy is not a direct contraindication for tadalafil use. Tadalafil is generally