A patient presents with knee pain and swelling following a fall onto a flexed knee. Physical examination reveals a palpable effusion and tenderness along the joint line. McMurray's test elicits pain and clicking with passive knee flexion and internal rotation. Which condition is most likely?

Correct Answer: B

Rationale: The presentation of knee pain and swelling following a fall onto a flexed knee, along with a palpable effusion and tenderness along the joint line, is highly suggestive of a meniscus injury. The McMurray's test specifically evaluates for meniscal tears. In this case, the presence of pain and clicking with passive knee flexion and internal rotation indicates a medial meniscus tear as the most likely diagnosis. Patellar tendinitis usually presents with anterior knee pain that is worsened by activities such as jumping or running. Lateral collateral ligament (LCL) sprain typically presents with lateral knee pain and instability. Quadriceps tendon rupture would present with significant weakness and inability to fully extend the knee, which is not described in this scenario.

Correct Answer: A

Rationale: The diagnostic examination for osteoporosis typically involves measuring bone density. This is usually done through a dual-energy x-ray absorptiometry (DEXA) scan, which is considered the gold standard for assessing bone density. Osteoporosis is characterized by decreased bone mass and deterioration of bone tissue, leading to increased bone fragility and risk of fractures. Measuring bone density helps in diagnosing osteoporosis by identifying areas of low bone density, assessing the risk of fractures, and monitoring the effectiveness of treatment. Weight, blood volume, and height are not directly used as primary indicators for diagnosing osteoporosis.

Correct Answer: C

Rationale: When caring for patients with hyperbilirubinemia, the nursing care plan should focus on informing the significant others, preventing injury, and preventing complications. The primary goal in managing hyperbilirubinemia is to prevent complications associated with high bilirubin levels, such as kernicterus. Therefore, maintaining physiological homeostasis with bilirubin levels increasing would not be appropriate and should not be the focus of the nursing care plan. It is crucial to monitor and manage bilirubin levels to prevent adverse outcomes rather than allowing them to increase.

Correct Answer: B

Rationale: The patient's presentation of sudden-onset weakness and sensory loss on one side of the body, along with difficulty speaking and understanding speech that partially resolved within one hour, is consistent with a transient ischemic attack (TIA). TIAs are caused by temporary disruption of blood flow to a part of the brain, leading to transient neurological symptoms. Unlike an ischemic stroke, which results in permanent damage to brain tissue due to prolonged interruption of blood flow, TIAs are transient and resolve within 24 hours. Hemorrhagic strokes and subarachnoid hemorrhages typically present with sudden, severe headaches, and may not improve or resolve quickly as seen in this case.

Correct Answer: A

Rationale: The step of the nursing process that identifies the family's health-seeking behavior is Assessment. During the assessment phase, the nurse gathers information about the family's health practices, beliefs, priorities, and past experiences related to seeking healthcare. This helps the nurse understand how the family approaches health and healthcare, which is crucial for providing tailored and effective care. By assessing the family's health-seeking behavior, the nurse can better collaborate with them to address their health needs and promote positive health outcomes.

Correct Answer: B

Rationale: Antipsychotic medications can cause metabolic side effects, including hyperglycemia (high blood sugar). Patients with bipolar disorder who are prescribed antipsychotic medications are at risk for developing new-onset diabetes or exacerbating preexisting diabetes. Monitoring blood glucose levels is essential to detect hyperglycemia early and prevent complications such as diabetic ketoacidosis. While hypertension, hypotension, and hypernatremia are possible side effects of certain medications, they are not typically associated with antipsychotic medications commonly used in the management of bipolar disorder. Hyperglycemia is a serious concern in this population due to the risk of developing diabetes or worsening of existing diabetes.

Correct Answer: C

Rationale: Carvedilol is a beta-blocker primarily used to manage heart failure and hypertension. Monitoring blood pressure closely during carvedilol therapy is crucial because it helps assess the drug's effectiveness in managing heart failure and controlling hypertension. Carvedilol works by blocking certain receptors in the heart and blood vessels, which can lower blood pressure. Monitoring blood pressure fluctuations allows healthcare providers to adjust the dosage accordingly to achieve optimal results and prevent potential complications in patients with heart failure. While monitoring blood glucose levels, serum potassium levels, and liver function tests are essential in managing other conditions or medications, the priority in a patient being prescribed carvedilol for heart failure is to monitor blood pressure levels.

Correct Answer: B

Rationale: Tiotropium (Spiriva) is an anticholinergic bronchodilator used for the management of COPD. A common side effect of anticholinergic medications is dry mouth. Rinsing the mouth with water after using the inhaler can help reduce the risk of developing oral thrush or other mouth infections due to dryness. This instruction helps promote good oral hygiene and decreases the potential side effects associated with tiotropium inhaler use. This teaching is important for patients to follow to ensure their overall health and well-being while using the medication.

Correct Answer: A

Rationale: Corticosteroids, commonly used in the treatment of nephrotic syndrome, can cause various side effects. One of the common side effects of corticosteroids is a loss of appetite. Patients receiving corticosteroid therapy may experience a decreased desire to eat, leading to reduced food intake. Monitoring for changes in appetite is important as a decrease in food intake can impact overall nutrition and may affect the patient's response to treatment. It is essential for the nurse to watch for this side effect to address any potential nutritional concerns and collaborate with the healthcare team to optimize the patient's care.