During the assessment of a 20-year-old patient with a 3-day history of nausea and vomiting, the nurse notes the following: dry mucosa and deep fissures in the tongue. This finding is indicative of:

Correct Answer: A

Rationale: The dry mucosa and deep fissures in the tongue indicate dehydration in the patient. Dehydration causes decreased saliva production, leading to dry mouth and tongue fissures. This is a common symptom of dehydration. The lack of moisture in the oral cavity can result in these physical signs. The other choices are incorrect because irritation by gastric juices typically presents with other symptoms, a normal oral condition would not show these specific findings, and side effects of nausea medication would not directly cause dry mucosa and deep fissures in the tongue. Therefore, the correct answer is A: dehydration.

Correct Answer: C

Rationale: The correct answer is C because the normal eardrum of a newborn can appear thick and opaque due to the presence of vernix or desquamated epithelium. Immobility of the drum (Choice A) is not a normal finding in a newborn and could indicate a problem. An "injected" membrane (Choice B) would suggest inflammation or infection, not necessarily infection. The appearance of the membrane in a newborn is not identical to that of an adult (Choice D) as it may have a different color, thickness, or opacity due to developmental differences.

Correct Answer: C

Rationale: Rationale for Correct Answer (C): 1. Immediate intervention is crucial as the newborn needs clear airways for breathing. 2. Inability to suction the nares can lead to respiratory distress and compromise the infant's oxygenation. 3. Waiting or attempting again may delay necessary actions, risking the baby's health. 4. Physician's assistance may be needed, but recognizing the urgency is the nurse's responsibility to ensure timely care. Summary of Incorrect Choices: A. Attempting to suction again with a bulb syringe may not resolve the issue and delay necessary intervention. B. Waiting for the infant to stop crying is not ideal as it may prolong the risk of respiratory distress. D. While physician assistance may be necessary, immediate recognition of the critical situation is the nurse's primary responsibility.

Correct Answer: B

Rationale: The correct answer is B. When using an otoscope to assess the nasal cavity, it is crucial to avoid touching the nasal septum with the speculum to prevent discomfort or injury to the patient. Touching the nasal septum can cause pain and potential damage. Incorrect Choices: A: Inserting the speculum at least 3 cm into the vestibule is not necessary and may cause discomfort or injury to the patient. C: Displacing the nose to the side being examined is not required and may not provide any additional benefit during the assessment. D: Keeping the speculum tip medial to avoid touching the floor of the nares is not as critical as avoiding contact with the nasal septum, which is more sensitive and can be easily injured.

Correct Answer: B

Rationale: The correct answer is B: pearly grey and slightly concave. This is because a healthy tympanic membrane should appear pearly grey in color and slightly concave in shape. The pearly grey color indicates normal transparency and reflection of light, while the slightly concave shape is indicative of a normal eardrum. Choice A is incorrect as a light pink color and slight bulge are not characteristic of a healthy tympanic membrane. Choice C is incorrect because a pulled-in appearance at the base of the cone of light suggests retraction, which is abnormal. Choice D is incorrect as a whitish color with a small fleck of light is not a typical presentation of a healthy tympanic membrane.

Correct Answer: A

Rationale: The correct answer is A because one pinch of smokeless tobacco (SLT) in the mouth for 30 minutes can indeed deliver a similar amount of nicotine as smoking one cigarette. This is because the nicotine in SLT is absorbed through the oral mucosa directly into the bloodstream, providing a quick effect. This statement is accurate and reflects the pharmacokinetics of SLT use. Option B is incorrect because smoking carries a higher risk of oral cancer compared to SLT use. Option C is incorrect as pain is not always an early sign of oral cancer, and other symptoms such as non-healing sores or lumps may indicate oral cancer. Option D is incorrect as pain can sometimes be an early sign of oral cancer, especially in advanced stages.

Correct Answer: D

Rationale: The correct answer is D because over-the-counter nasal sprays, especially those containing decongestants, can lead to rebound swelling when used for an extended period. Rebound swelling occurs when the nasal passages become more congested after the effects of the medication wear off. This can result in a cycle of dependency on the nasal spray to alleviate symptoms, leading to worsening congestion over time. It is important for the nurse to educate the patient about this potential risk and suggest alternative treatment options to address her allergies effectively without causing rebound swelling. Choices A, B, and C are incorrect because: A: Incorrect, as not all over-the-counter nasal sprays carry a risk of addiction. B: Incorrect, as switching to another brand may not address the underlying issue of rebound swelling. C: Incorrect, as continuous use of the nasal spray without addressing rebound swelling can exacerbate the problem.

Correct Answer: C

Rationale: The correct answer is C: Spoon nails. In iron-deficiency anemia, the nails may develop a concave or spoon-like shape (koilonychia). This is due to the decreased oxygen supply to the nail bed. The characteristic spoon nails are indicative of severe iron deficiency. Splinter hemorrhages (choice A) are small areas of bleeding under the nails and are more commonly associated with conditions like endocarditis. Paronychia (choice B) is an infection around the nail, not specific to anemia. Beau's lines (choice D) are horizontal depressions in the nails, typically seen after a period of severe illness or stress, rather than specifically in iron-deficiency anemia.

Correct Answer: B

Rationale: The correct answer is B. When a patient experiences nosebleeds, the best way to stop it is by sitting straight with the head tilted slightly forward and pinching the nose firmly for about 10-15 minutes. This position helps reduce blood flow to the nose and promotes clotting. It is important not to tilt the head back as it can lead to blood going down the throat and potentially causing choking or vomiting. Cold compresses can also be applied to help constrict blood vessels. Choices A, C, and D are incorrect as they do not follow the proper technique for managing nosebleeds and can potentially worsen the situation.