An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?

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Question 1 of 9

An advanced practice nurse has performed a Rinne test on a new patient. During the test, the patient reports that air-conducted sound is louder than bone-conducted sound. How should the nurse best interpret this assessment finding?

Correct Answer: A

Rationale: The correct answer is A: The patient's hearing is likely normal. This interpretation is based on the normal Rinne test result, where air-conducted sound is expected to be louder than bone-conducted sound. This finding indicates that the patient has intact air conduction and no significant conductive hearing loss. Option B is incorrect because tinnitus is not directly related to the Rinne test results. Option C is incorrect as otosclerosis would typically present with abnormal Rinne test results showing bone-conducted sound to be louder. Option D is incorrect as sensorineural hearing loss would not typically affect the Rinne test results in this way.

Question 2 of 9

A patient has just been diagnosed with prostate cancer and is scheduled for brachytherapy next week. The patient and his wife are unsure of having the procedure because their daughter is 3 months pregnant. What is the most appropriate teaching the nurse should provide to this family?

Correct Answer: B

Rationale: The correct answer is B because brachytherapy does not pose a risk to the patient's daughter or her unborn child. Brachytherapy involves placing radioactive sources inside or near the tumor, which does not make the patient radioactive. The radiation does not travel far and does not pose a risk to others. Therefore, the daughter and her infant are safe from any radiation exposure. Choices A, C, and D are incorrect because there is no need for the patient to avoid contact with the baby after delivery, the brachytherapy is not contraindicated for safety reasons, and there is no requirement for the patient to avoid close contact with his daughter for 2 months.

Question 3 of 9

A school nurse is caring for a child who appears to be having an allergic response. What should be the initial action of the school nurse?

Correct Answer: A

Rationale: The correct initial action for the school nurse is to assess for signs and symptoms of anaphylaxis (Choice A). This is crucial as anaphylaxis is a severe allergic reaction that can be life-threatening and requires immediate intervention. Assessing for anaphylaxis symptoms such as difficulty breathing, swelling of the face or throat, and a rapid pulse helps the nurse quickly identify the severity of the situation. Administering OTC antihistamines (Choice C) or epinephrine (Choice D) should only be done after confirming the presence of anaphylaxis. Assessing for erythema and urticaria (Choice B) is important but not as immediate as assessing for signs of anaphylaxis in this scenario.

Question 4 of 9

A patient diagnosed with a pituitary adenoma has arrived on the neurologic unit. When planning the patients care, the nurse should be aware that the effects of the tumor will primarily depend on what variable?

Correct Answer: B

Rationale: The correct answer is B: The specific hormones secreted by the tumor. Pituitary adenomas are known to secrete hormones that can lead to various endocrine disorders. Understanding the specific hormones secreted by the tumor is crucial in determining the clinical manifestations and planning appropriate treatment. Choices A, C, and D are incorrect because the primary determinant of the effects of the tumor in this case is the hormonal activity rather than whether the tumor uses aerobic or anaerobic respiration, the patient's pre-existing health status, or whether the tumor is primary or metastatic.

Question 5 of 9

A 23-year-old woman comes to the free clinic stating I think I have a lump in my breast. Do I have cancer? The nurse instructs the patient that a diagnosis of breast cancer is confirmed by what?

Correct Answer: B

Rationale: The correct answer is B: Mammography. Mammography is the gold standard for diagnosing breast cancer as it can detect abnormalities such as lumps or tumors in the breast tissue. It provides detailed images that can help healthcare providers identify suspicious areas that may require further testing or biopsy. Supervised breast self-examination (choice A) is important for early detection but is not a diagnostic tool. Fine-needle aspiration (choice C) is a procedure used to obtain a sample of cells for further analysis but is not definitive for diagnosing breast cancer. Chest x-ray (choice D) is used to evaluate the lungs and heart, not the breast tissue for cancer.

Question 6 of 9

The hospice nurse is caring for a 45-year-old mother of three young children in the patients home. During the most recent visit, the nurse has observed that the patient has a new onset of altered mental status, likely resulting from recently diagnosed brain metastases. What goal of nursing interventions should the nurse identify?

Correct Answer: D

Rationale: The correct answer is D. The goal of nursing interventions in this scenario is to teach family members how to interact with and ensure safety for the patient with impaired cognition. This is the most appropriate response because it addresses the immediate need to provide the patient with appropriate care and support in their home environment. By educating the family on how to interact with the patient and ensure their safety, the nurse can help maintain a sense of normalcy for the patient and promote their well-being. Choice A is incorrect because sedating the patient may not be the best approach without considering other interventions first. Choice B is incorrect as moving the patient to an acute-care facility may not be necessary or feasible at this time. Choice C is incorrect as it focuses on end-of-life care rather than addressing the immediate need of supporting the patient with altered mental status.

Question 7 of 9

A nurse is preparing a bowel training programfor a patient. Which actions will the nurse take? (Select all that apply.)

Correct Answer: A

Rationale: The correct answer is A. Recording times when the patient is incontinent is crucial in identifying patterns and establishing a structured bowel training program. This data helps in determining the optimal timing for toileting. Choices B, C, and D are incorrect. Choice B is not specific to bowel training and may not address the patient's individual needs. Choice C is not a recommended posture for effective bowel elimination. Choice D, while important for overall health, is not directly related to bowel training.

Question 8 of 9

A patient, who delivered her third child yesterday, has just learned that her two school-age children have contracted chickenpox. What should the nurse tell her?

Correct Answer: D

Rationale: The correct answer is D: She must make arrangements to stay somewhere other than her home until the children are no longer contagious. 1. The patient's newborn is at risk of contracting chickenpox from the infected children. 2. Chickenpox can be severe in newborns due to their immature immune systems. 3. It is crucial to protect the newborn by ensuring they are not exposed to the virus. 4. Staying elsewhere until the children are no longer contagious will prevent transmission to the newborn. Incorrect choices: A: Acyclovir is not recommended for prophylactic treatment in this situation. B: Immunity is not automatically transferred from the mother to the baby for chickenpox. C: Allowing the infected children to visit with precautions is not sufficient to protect the newborn.

Question 9 of 9

In general, when a patient’s energy requirements are completely met by kilocalorie (kcal) intake in food, which assessment finding will the nurse observe?

Correct Answer: C

Rationale: The correct answer is C: Weight does not change. When a patient's energy requirements are completely met by kcal intake, their weight should remain stable as there is a balance between energy intake and expenditure. This indicates that the body is receiving adequate energy for its needs, leading to weight maintenance. A: Weight increases - This would indicate an excess of energy intake over expenditure, leading to weight gain. B: Weight decreases - This would indicate a deficit in energy intake compared to expenditure, resulting in weight loss. D: Weight fluctuates daily - Daily weight fluctuations are normal and can be influenced by factors like hydration levels, food intake, and exercise, but a stable weight over time indicates a balance between energy intake and expenditure.

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