Identify the placement of the stapes footplate into the bony labyrinth.
- A. Fenestra vestibuli
- B. Fenestra cochleae
- C. Tympanic membrane
- D. Round window
Correct Answer: A
Rationale: The correct answer is A: Fenestra vestibuli. The stapes footplate is placed into the fenestra vestibuli of the bony labyrinth. This structure is also known as the oval window and is located at the junction of the middle ear and inner ear. Choice B, Fenestra cochleae, is incorrect as this opening is also known as the round window and is located near the base of the cochlea. Choice C, Tympanic membrane, is incorrect as it is also known as the eardrum and separates the external ear from the middle ear. Choice D, Round window, is incorrect as it is the opening covered by the secondary tympanic membrane and is important for the dissipation of sound waves in the cochlea.
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An elderly client with Alzheimer's disease is being admitted to a long-term care facility. The client's spouse expresses concern about the level of care the client will receive. What is the most appropriate response by the nurse?
- A. Reassure the spouse that the client will be well cared for and provide information about the facility's care practices.
- B. Inform the spouse that care will be adjusted based on the client's condition and needs.
- C. Advise the spouse to visit frequently to monitor the quality of care the client receives.
- D. Suggest that the spouse speak with other family members for reassurance.
Correct Answer: A
Rationale: The most appropriate response by the nurse in this situation is to reassure the spouse that the client will be well cared for and provide information about the facility's care practices. This response not only addresses the spouse's concerns directly but also helps in building trust and confidence in the care provided. Choice B is not ideal as it may cause unnecessary worry about the fluctuating care levels. Choice C puts the responsibility on the spouse to monitor care, which may not always be feasible or appropriate. Choice D deflects the concern to other family members instead of addressing the spouse's worries directly.
In Duchenne muscular dystrophy, if a child has a Gower sign, what behavior should the nurse expect the child to exhibit?
- A. Stands from sitting on the floor by using hands to walk up legs
- B. Exhibits muscular atrophy of upper and lower extremities
- C. Is unable to stand because of contractures of both hips
- D. Walks with an unsteady gait and slaps feet on the floor
Correct Answer: A
Rationale: The Gower sign is a characteristic finding in Duchenne muscular dystrophy where a child uses hands to walk up the legs when standing from a sitting position due to proximal muscle weakness. This behavior is indicative of the child trying to compensate for weak hip and thigh muscles. Choices B, C, and D are incorrect because they do not describe the specific behavior associated with the Gower sign. Muscular atrophy, contractures of both hips, and an unsteady gait with foot slapping are not directly related to the Gower sign.
The nurse is assigned to care for a client diagnosed with psoriasis. What behavior by the nurse addresses this client's psychosocial need for acceptance?
- A. Wearing gloves when providing care to the client
- B. Encouraging the client to join a support group
- C. Shaking hands with the client during an introduction
- D. Allowing the client to express their feelings openly
Correct Answer: B
Rationale: Encouraging the client to join a support group is the best option to address the client's psychosocial need for acceptance. Support groups provide a sense of belonging, understanding, and acceptance from peers who share similar experiences. This helps the client feel accepted despite their condition. Wearing gloves when providing care, shaking hands during an introduction, and allowing the client to express feelings openly are important but do not directly address the client's need for acceptance.
An older male client is admitted to the mental health unit with a sudden onset of global disorientation and is continuously conversing with his mother, who died 50 years ago. The nurse reviews the multiple prescriptions the client is currently taking and assesses his urine specimen, which is cloudy, dark yellow, and has a foul odor. These findings suggest that this client is experiencing which condition?
- A. Psychotic episode
- B. Dementia
- C. Delirium
- D. Depression
Correct Answer: C
Rationale: The correct answer is C, delirium. The sudden onset of global disorientation along with cloudy, dark yellow urine with a foul odor are indicative of delirium. Delirium is an acute condition characterized by a fluctuating disturbance in awareness and cognition. In this case, the symptoms are suggestive of an underlying physiological cause, such as infection or medication side effects. Choice A, psychotic episode, is less likely as the symptoms are more in line with delirium than a primary psychotic disorder. Choice B, dementia, is a chronic and progressive condition, not typically presenting with sudden onset disorientation. Choice D, depression, does not align with the acute cognitive changes and urine abnormalities described in the scenario.
When taking a health history of a client admitted with acute pancreatitis, which client complaint should be expected?
- A. A low-grade fever and left lower abdominal pain
- B. Severe headache and sweating all the time
- C. Severe mid-epigastric pain after ingesting a heavy meal
- D. Dull, continuous, right lower quadrant pain and nausea
Correct Answer: C
Rationale: The correct answer is C: 'Severe mid-epigastric pain after ingesting a heavy meal.' This symptom is characteristic of acute pancreatitis due to inflammation of the pancreas, which often presents with severe pain in the mid-epigastric region that may worsen after eating. Choices A, B, and D describe symptoms that are not typically associated with acute pancreatitis. A low-grade fever and left lower abdominal pain (Choice A) may be more indicative of other conditions like diverticulitis. Severe headache and sweating (Choice B) are commonly seen in conditions like migraines or infections. Dull, continuous, right lower quadrant pain and nausea (Choice D) could be suggestive of appendicitis rather than acute pancreatitis.