A patient presents with acute knee pain and swelling following a twisting injury during sports activity. Physical examination reveals joint effusion and tenderness along the joint line. Which structure is most likely injured in this scenario?

Correct Answer: C

Rationale: The scenario described is suggestive of a meniscus injury. A twisting injury during sports activity leading to acute knee pain and swelling, accompanied by joint effusion and tenderness along the joint line, is commonly associated with meniscus tears. The meniscus is a C-shaped cartilage structure located between the femur and tibia in the knee joint, providing cushioning and stability. The symptoms of a meniscus tear typically include pain, swelling, joint line tenderness, and sometimes mechanical symptoms like locking or clicking. Treatment may involve rest, physical therapy, or in some cases, surgery to repair or remove the torn meniscus.

Correct Answer: D

Rationale: Restlessness caused by pain often manifests as increased perspiration and constant change of position. When a person is in pain, they may become sweaty or clammy due to increased sympathetic nervous system activity. Additionally, they may constantly shift or fidget in an attempt to find a more comfortable position that can alleviate the pain they are experiencing. Therefore, it is crucial for Nurse Chona to accurately document these behaviors as signs of pain-related restlessness. Difficulty of breathing (Option A), increased respiratory rate and blood pressure (Option B), and increased heart rate (Option C) are more indicative of hypoxia or respiratory distress rather than pain-related restlessness.

Correct Answer: B

Rationale: The most appropriate nursing diagnosis for the individual described is "Ineffective individual coping." This is because the individual has been facing challenges in both academic (failing math class) and personal (substance dependence) aspects of his life. The repeated failures in his math class and the substance dependence for three years indicate that he might be struggling to cope with stressors and challenges in his life effectively. By identifying this nursing diagnosis, the nurse can focus on helping the individual develop effective coping strategies to manage and overcome these difficulties.

Correct Answer: C

Rationale: In pneumothorax, air enters the normally negative pressure space between the lung and chest wall, leading to loss of negative intra-pleural pressure. However, this loss of negative pressure typically does not directly result in lung collapse. Instead, the accumulation of air in the pleural space can lead to a pressure imbalance, causing the lung to collapse partially or completely, which is known as atelectasis. Therefore, it is more accurate to state that the loss of negative intra-pleural pressure can result in lung collapse due to the presence of air in the pleural space, rather than the loss of negative pressure itself causing the collapse.

Correct Answer: D

Rationale: The bio-ethical principle of veracity pertains to honesty and truthfulness in healthcare communication. By providing fraudulent information about the patient's diagnosis and prognosis, the nurse would be violating the principle of veracity. It is crucial for healthcare providers to be honest and provide accurate information to patients in order to ensure informed decision-making and uphold the trust between healthcare professionals and their patients. Misleading a patient about their diagnosis and prognosis can have serious consequences on the patient's understanding of their condition, treatment decisions, and overall well-being. Therefore, maintaining honesty and truthfulness is essential in promoting ethical healthcare practices.

Correct Answer: C

Rationale: Placing the patient on an alternating pressure mattress demonstrates evidence-based practice in pressure injury prevention. Alternating pressure mattresses are designed to change pressure points by alternating pressure across different parts of the body, reducing the risk of pressure injuries. Regularly turning and repositioning the patient (Choice B) is also important in preventing pressure injuries, but an alternating pressure mattress provides additional support and prevention measures. Applying moisturizing lotion (Choice A) and massaging bony prominences (Choice D) may be beneficial for skin care, but they are not proven strategies for pressure injury prevention.

Correct Answer: A

Rationale: Encouraging frequent position changes, including the hands-and-knees position, is the most appropriate nursing intervention in this scenario. This position is known to help rotate the baby from a persistent posterior position to an optimal anterior position for delivery. The hands-and-knees position can help take pressure off the mother's back, alleviate back pain, and facilitate the rotation of the baby's head to engage in the mother's pelvis, thus promoting labor progress. It is a non-invasive and effective way to promote fetal rotation without the need for immediate instrumental delivery or intravenous analgesics. Continuous fetal monitoring is important for assessing fetal well-being but would not directly address the issue of posterior fetal position and the associated prolonged labor.

Correct Answer: B

Rationale: It is important for the nurse to have a direct and easily accessible means of communication with the patient who is expected to be in and out of the hospital due to their chronic illness like leukemia. By asking for the patient's phone number, the nurse can quickly reach out to them for updates, clarification, or any urgent matters that may arise. This direct communication line helps in ensuring continuity of care and addressing the patient's needs promptly. This approach is more practical and efficient compared to options such as asking the patient to call the hospital number listed in the yellow pages or relying on chart information which may not always be up to date. Writing down the number and giving it to the ward clerk may cause unnecessary delays in communication.

Correct Answer: C

Rationale: Acute appendicitis is the most likely cause of the symptoms described in the pregnant woman. The classic presentation of acute appendicitis includes fever, chills, abdominal pain localized to the right lower quadrant, rebound tenderness, and guarding. Pregnant women are at a slightly higher risk of developing appendicitis due to anatomic changes and increased abdominal pressure during pregnancy, which can lead to an atypical presentation of symptoms. Prompt diagnosis and surgical intervention are crucial to prevent complications such as perforation, which can be detrimental for both the mother and the fetus.