Correct Answer: B

Rationale: Ramsay Hunt syndrome is caused by the varicella-zoster virus affecting the geniculate ganglion, leading to a triad of symptoms known as the Hunt syndrome: facial paralysis, ear pain, and a vesicular rash in the ear or palate. The facial paralysis in Ramsay Hunt syndrome is usually peripheral, similar to Bell's palsy, but may be more severe. In addition to facial paralysis, the patient may have the inability to close the eye on the affected side (lagophthalmos) and loss of taste sensation on the anterior two-thirds of the tongue due to involvement of the chorda tympani nerve. This differentiation is important to consider in the context of our patient's presentation.

Correct Answer: D

Rationale: Using colored pictures can help make the presentation of the plan more visually engaging and easier to understand for the audience, in this case, the nurse's intended audience. Visual aids, such as colored pictures, can effectively convey complex information in a simplified and easy-to-digest manner. This approach can enhance comprehension and retention of the presented material, making the implementation of the plan more accessible and clear to the individuals involved.

Correct Answer: B

Rationale: The nurse's appropriate response is to provide the requested information clearly and directly. In this case, the client asked for the time, so the best response is to say "It is 10 o'clock" to answer their question promptly. Options A, C, and D do not address the client's question and may be perceived as dismissive or unhelpful.

Correct Answer: D

Rationale: An advance directive is a legal document that specifies a person's healthcare preferences and instructions for medical treatment in the event they are unable to communicate their wishes. It typically includes decisions about life-sustaining treatments, resuscitation, and end-of-life care. In the scenario provided, the document provided by the patient to the nurse outlining his healthcare team's instructions postoperatively indicates that he has an advance directive in place to guide his medical care if necessary. In contrast, informed consent is a process in which a patient gives permission for medical treatment after being informed about the risks, benefits, and alternatives. Patient's Bill of Rights outlines the patient's rights within the healthcare system, and an insurance card provides information about the patient's insurance coverage.

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.