A patient presents with recurrent episodes of sudden, severe vertigo lasting hours, accompanied by nausea, vomiting, and nystagmus. Vestibular function tests demonstrate unilateral weakness. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: A

Rationale: The patient's presentation of recurrent episodes of sudden, severe vertigo lasting hours with nausea, vomiting, and nystagmus, along with unilateral weakness on vestibular function tests, is most consistent with vestibular neuritis. Vestibular neuritis is characterized by inflammation of the vestibular nerve leading to sudden onset vertigo that can last for hours to days. It is often associated with nausea, vomiting, and nystagmus. Unilateral weakness on vestibular function tests indicates dysfunction of one vestibular system. Differential diagnosis for this type of presentation includes other conditions such as Meniere's disease, BPPV, and acoustic neuroma. However, the combination of symptoms and unilateral vestibular weakness makes vestibular neuritis the most likely diagnosis in this case.

Correct Answer: B

Rationale: The nurse should prioritize cleansing the insertion site with an alcohol-based antiseptic solution to maintain procedural asepsis during a peripherally inserted central catheter (PICC) insertion. Proper skin preparation is essential in reducing the risk of introducing pathogens into the patient's bloodstream during the insertion process. Alcohol-based antiseptic solutions are effective in reducing the number of microorganisms on the skin surface. Wearing sterile gloves and following other sterile techniques are also crucial, but preparing the insertion site with the antiseptic solution is the initial step in maintaining asepsis during the procedure.

Correct Answer: C

Rationale: The most appropriate nursing action when a postpartum client presents with persistent, severe headache, photophobia, and altered mental status is to notify the healthcare provider immediately. These symptoms could be indicative of serious conditions such as postpartum preeclampsia or postpartum eclampsia, both of which require prompt medical evaluation and intervention. Delaying medical attention in such cases can lead to severe complications for the mother. Therefore, it is crucial to prioritize the client's safety and well-being by quickly involving the healthcare provider for further assessment and management.

Correct Answer: D

Rationale: A trimalleolar fracture is characterized by fractures involving the lateral malleolus (distal fibula), medial malleolus (distal tibia), and the posterior tubercle of the distal tibia. This fracture pattern results in instability of the ankle joint and is often associated with widening of the ankle mortise on X-ray. The deformity and swelling seen in this patient are indicative of a trimalleolar fracture and are typically caused by a high-energy injury, such as a forceful twisting motion. Treatment for trimalleolar fractures often involves surgical intervention to stabilize the ankle joint and restore normal function.

Correct Answer: D

Rationale: Thrombocytopenia is a condition characterized by a low platelet count, which can lead to an increased risk of bleeding. Patients with thrombocytopenia are at risk for injury due to potential bleeding complications. Therefore, the appropriate nursing diagnosis to protect the patient from further injury in this case would be "Risk for injury related to thrombocytopenia." This nursing diagnosis allows the nurse to assess for signs of bleeding, implement interventions to prevent injury, and closely monitor the patient's platelet levels to prevent complications.

Correct Answer: D

Rationale: Erosion is the dental condition characterized by the destruction of tooth structure due to exposure to acidic substances, such as gastric acid from conditions like gastroesophageal reflux disease (GERD) or acidic beverages like sodas and citrus fruits. This acidic attack softens and wears away the enamel, leading to the erosion of tooth structure. Unlike dental caries, which is caused by bacteria producing acid from sugars in the mouth, erosion is primarily a result of external acidic sources. Attrition refers to the wear of tooth structure from tooth-to-tooth contact, and abrasion refers to the wear of tooth structure due to forces like brushing too hard or using abrasive toothpaste.

Correct Answer: C

Rationale: The initial step of delegation is to determine the competency level of the staff for the task being given. Before delegating a task, a nurse must assess the knowledge, skills, and abilities of the staff member to ensure that they are competent and capable of performing the task safely and effectively. This step is crucial in ensuring that tasks are delegated appropriately and that quality patient care is maintained. By determining the competency level of the staff, Nurse Gayle can make informed decisions about delegation, provide appropriate support and resources, and facilitate effective communication throughout the delegation process.

Correct Answer: B

Rationale: Ectopic pregnancy is a common complication of untreated gonorrhea or chlamydia infection in women. This occurs when a fertilized egg implants and grows outside the uterus, typically in one of the fallopian tubes. Both gonorrhea and chlamydia can lead to scarring of the fallopian tubes due to untreated inflammation and infection. This scarring may obstruct the fallopian tubes, making it difficult for the fertilized egg to travel to the uterus for implantation. As a result, the egg may implant and grow in the fallopian tube, leading to an ectopic pregnancy. Ectopic pregnancies are dangerous and can result in serious complications for the woman, including rupture of the fallopian tube, internal bleeding, and potentially life-threatening situations. It is crucial to seek prompt treatment for gonorrhea and chlamydia to prevent such severe outcomes.

Correct Answer: B

Rationale: The pharynx is the structure responsible for transporting food from the oral cavity to the esophagus during swallowing. When food is chewed and mixed with saliva in the oral cavity, it forms a bolus that is propelled to the pharynx by the tongue. The pharynx serves as a common passageway for both air and food, allowing the bolus to pass into the esophagus while preventing it from entering the trachea. The epiglottis, although important in preventing food from entering the airway, is not directly involved in the transportation of food from the oral cavity to the esophagus.