A patient presents with sudden-onset severe headache, altered mental status, and focal neurological deficits. Imaging reveals a hemorrhagic lesion within the right basal ganglia. Which of the following neurological conditions is most likely responsible for these symptoms?

Correct Answer: C

Rationale: Intracerebral hemorrhage occurs when there is bleeding directly into the brain tissue, often due to conditions such as hypertension or vascular malformations. The sudden-onset severe headache, altered mental status, and focal neurological deficits described in the patient are typical symptoms of an intracerebral hemorrhage. The location of the hemorrhagic lesion within the right basal ganglia corresponds to the clinical presentation. Ischemic stroke, subarachnoid hemorrhage, and transient ischemic attack (TIA) typically have different presentations and imaging findings compared to an intracerebral hemorrhage. Therefore, in this scenario, intracerebral hemorrhage is the most likely cause of the patient's symptoms.

Correct Answer: A

Rationale: The nurse should prioritize screening the patient for contraindications to MRI, such as metal implants or claustrophobia, to ensure procedural safety. Metallic objects can be hazardous in an MRI environment as they can be attracted to the magnet, potentially causing harm to the patient or staff. Claustrophobia can also be a significant issue for patients undergoing an MRI scan, and identifying this beforehand allows for appropriate measures to be taken to address the patient's anxiety or discomfort. Prioritizing this screening step helps ensure the safety and well-being of the patient during the MRI procedure.

Correct Answer: A

Rationale: Statement II is correct because the use of corticosteroids for multiple immune conditions can lead to the development of Cushing's disease.

Correct Answer: B

Rationale: Heart failure is a condition in which the heart is unable to pump enough blood to meet the body's need for oxygen and nutrients. Ineffective tissue perfusion is a relevant nursing diagnosis for a client with heart failure because the heart's inability to effectively pump blood can lead to poor perfusion of tissues and organs, resulting in inadequate oxygen and nutrient delivery to cells. This can lead to symptoms such as fatigue, dyspnea, and edema, which are common in individuals with heart failure. By addressing ineffective tissue perfusion, nurses can focus on interventions to improve cardiac output and optimize tissue perfusion, ultimately improving the client's overall condition.

Correct Answer: A

Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.

Correct Answer: B

Rationale: The constellation of severe lower abdominal pain, fever, and vaginal discharge in a pregnant woman raises suspicion for pelvic inflammatory disease (PID). Cervical motion tenderness and adnexal tenderness are classic physical exam findings for PID. The presence of bilateral adnexal masses further supports the diagnosis, as PID can lead to the formation of tubo-ovarian abscesses. Ectopic pregnancy may present with similar symptoms but is less likely in this case as bilateral adnexal masses suggest a more diffuse inflammatory process. Placenta previa would typically present with painless vaginal bleeding in the third trimester, which is not consistent with the symptoms described. Ovarian torsion would present with sudden severe unilateral lower abdominal pain and is less likely to involve both ovaries simultaneously.

Correct Answer: A

Rationale: The clinical presentation of fatigue, pallor, exertional dyspnea along with the laboratory findings of severe anemia, low serum iron, low transferrin saturation, and elevated TIBC are consistent with iron deficiency anemia. In iron deficiency anemia, there is inadequate iron available for erythropoiesis leading to microcytic hypochromic anemia. The low serum iron and transferrin saturation, along with the elevated TIBC, indicate decreased iron stores and increased iron-binding capacity as the body tries to compensate for the deficiency by increasing absorption and recycling of iron. Anemia of chronic disease typically presents with mild to moderate anemia, normal to low TIBC, and low transferrin saturation due to iron sequestration in macrophages. Sideroblastic anemia usually has elevated serum iron, high saturation, and normal to low TIBC. Thalassemia presents with microcytic hyp

Correct Answer: C

Rationale: Anticonvulsant medications, such as phenytoin and phenobarbital, can interfere with pregnancy tests by affecting the levels of human chorionic gonadotropin (hCG) in the body. HCG is the hormone detected in pregnancy tests. These medications may potentially lead to a false-negative result on a pregnancy test for women who are actually pregnant. Therefore, in the case of Almira, who is 6 months pregnant and taking anticonvulsant medication due to the risk of producing a false-negative pregnancy test result, healthcare providers should consider other clinical indicators, such as abdominal cramps and vaginal spotting, to assess her pregnancy status.

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.