A patient presents with sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea. Otoscopic examination reveals a bulging, erythematous tympanic membrane with obscured landmarks. Which of the following conditions is most likely responsible for this presentation?

Correct Answer: B

Rationale: Acute otitis media is the most likely condition responsible for this presentation. The sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea are classic symptoms of acute otitis media. Otoscopic examination revealing a bulging, erythematous tympanic membrane with obscured landmarks further supports the diagnosis. The bulging of the tympanic membrane is due to the accumulation of fluid and pus behind it, causing the characteristic appearance. Treatment typically involves antibiotics to help clear the infection and relieve symptoms. If left untreated, acute otitis media can lead to complications such as perforation of the eardrum or mastoiditis.

Correct Answer: A

Rationale: A woman experiencing irregular and ineffective uterine contractions with prolonged cervical dilation may indicate labor dystocia, also known as abnormal labor progression. To address this issue, the nursing intervention that should be implemented is to encourage the mother to ambulate and change positions frequently. This can help optimize fetal positioning and encourage descent through the birth canal by using gravity to aid in the progression of labor. Changing positions can also potentially improve the quality and effectiveness of contractions, leading to more successful cervical dilation and labor progress. Encouraging ambulation and position changes are non-invasive, patient-centered interventions that can be helpful in managing labor dystocia before considering more invasive interventions like cesarean section.

Correct Answer: B

Rationale: The ethical principle of autonomy emphasizes respecting the patient's right to make their own decisions regarding their treatment. In this scenario, the patient has the right to refuse treatment, and the nurse should respect that decision while also providing information and guidance to help the patient make informed choices. By upholding the principle of autonomy, the nurse can support the patient's decision-making process and work collaboratively with them to address any concerns or barriers to compliance with the treatment regimen. This approach honors the patient's right to self-determination and promotes a trusting relationship between the nurse and the patient.

Correct Answer: B

Rationale: Baby Sharon's APGAR score can be determined by assessing five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each criteria is given a score of 0, 1, or 2 points, with 2 being the highest score.

Correct Answer: B

Rationale: Teaching the patient diaphragmatic breathing exercises for respiratory support would be the most appropriate intervention to address the symptoms of dyspnea and anxiety in this scenario. Diaphragmatic breathing, also known as belly breathing, focuses on engaging the diaphragm for deep, slow breaths, which can help improve lung expansion and ventilation. This technique can help the patient manage their breathing difficulty and reduce anxiety by promoting relaxation and improving oxygen exchange in the lungs. It empowers the patient with a coping strategy they can use independently to alleviate distressing symptoms at any time. Administering oxygen therapy may be beneficial, but the priority is to teach the patient a technique they can use proactively and routinely. Prescribing benzodiazepines should be considered as an adjunct if non-pharmacological interventions are ineffective in managing anxiety. Referring to a pulmonologist may be necessary for comprehensive evaluation and treatment but may not directly address the immediate symptoms of dyspnea and anxiety.

Correct Answer: A

Rationale: The incident report is the best source of factual information to investigate the fall further. Incident reports are official documents that provide a detailed account of what happened leading up to and during an incident. They include factual information such as the date, time, location, individuals involved, and details of the event. By reviewing the incident report, investigators can gather accurate information to determine the cause of the fall and any contributing factors. This document serves as an essential tool in conducting a thorough investigation into the fall and helps in identifying preventive measures to avoid similar incidents in the future.

Correct Answer: B

Rationale: The nurse's best approach to address non-compliance with prescribed medications and treatment plans is to actively listen to the patient's reasons for non-compliance. By acknowledging and addressing any barriers or concerns the patient may have, the nurse can work collaboratively with the patient to find effective solutions. This approach promotes open communication, trust, and a patient-centered care plan that takes into consideration the patient's individual needs and circumstances. Dismissing the patient's reasons (choice A), ignoring the non-compliance (choice C), or resorting to a confrontational approach (choice D) are less effective strategies that may lead to further resistance and hinder the patient's willingness to engage in their treatment.

Correct Answer: A

Rationale: Smoking is a harmful habit that is known to contribute to a variety of health problems, including heart disease, lung disease, and cancer. Smoking does not provide any benefits for Alzheimer's patients and, in fact, can worsen the condition due to its negative impact on overall health. Therefore, smoking does not help improve Alzheimer's and may exacerbate the symptoms and complications associated with the disease.

Correct Answer: B

Rationale: The patient who had a left total hip replacement surgery due to osteoarthritis needs to strictly follow the postoperative teaching of being shown how to gently irrigate the external auditory canal because this instruction is unrelated to a hip replacement surgery. The other options are not relevant to the surgery and patient's condition. Option A about airplane travel, Option C about dizziness, and Option D about hair washing are not appropriate instructions for a patient who had a hip replacement. It is important for healthcare providers to give accurate and relevant postoperative instructions to help the patient recover successfully.