During the examination of a patient in her third trimester of pregnancy, the nurse notices that the patient's thyroid gland is slightly enlarged. No enlargement had been noted previously. The nurse suspects that:

Correct Answer: C

Rationale: Step-by-step rationale for why choice C is correct: 1. Enlargement of the thyroid gland during pregnancy is a normal finding due to hormonal changes. 2. The thyroid gland enlarges to meet the increased demands of thyroid hormone production. 3. This condition is known as gestational thyrotoxicosis and is usually benign. 4. No further testing is needed for thyroid cancer unless other concerning symptoms are present. Summary: A: Not relevant as iodine deficiency is not typically associated with thyroid enlargement in pregnancy. B: Incorrect as early signs of goitre would involve more pronounced symptoms than just slight enlargement. D: Unnecessary as thyroid cancer is not a common concern in this scenario of a slightly enlarged thyroid in the third trimester of pregnancy.

Correct Answer: C

Rationale: Step 1: The described behavior is known as the asymmetric tonic neck reflex (ATNR), a normal infantile reflex. Step 2: The ATNR typically emerges around birth and should disappear between 3 and 4 months of age. Step 3: The reflex helps with hand-eye coordination and development of body awareness. Step 4: Choice A is incorrect as the behavior is not abnormal or related to atonic neck reflex. Step 5: Choice B is incorrect as the reflex typically disappears by 3-4 months, not by the first year of life. Step 6: Choice D is incorrect as it describes a different pattern of movement than what is observed in the ATNR. Summary: The correct answer is C because the behavior described is a normal infantile reflex that typically disappears between 3-4 months of age, aiding in the baby's development.

Correct Answer: C

Rationale: The correct answer is C: Mental. Nursing assessments typically include physical, focused, and emergency assessments. Mental assessments are more commonly associated with psychiatric nursing rather than general nursing assessments. Mental assessments focus on assessing a patient's mental status, emotions, and cognitive functions, which are not typically part of routine nursing assessments. Therefore, mental assessments do not fall under the types of assessments typically performed by general nurses.

Correct Answer: D

Rationale: The correct answer is D because floaters are a common and typically benign phenomenon caused by condensed vitreous fibers in the eye. A nurse should educate the patient that floaters are usually not significant and do not require immediate intervention. Option A is incorrect because counting the number of floaters is unnecessary. Option B is incorrect because presuming glaucoma without proper assessment is inappropriate. Option C is incorrect because seeing occasional floaters is a common and normal occurrence in many individuals.

Correct Answer: D

Rationale: The correct answer is D because testing for strabismus by performing the corneal light reflex test is crucial in diagnosing "lazy eye" or amblyopia in children. Strabismus is a condition where the eyes are misaligned, leading to poor vision in one eye. By performing the corneal light reflex test, the nurse can assess if the child's eyes are aligned or if there is deviation, which could indicate lazy eye. Options A, B, and C are incorrect as they do not specifically address the assessment of strabismus, which is the key indicator for lazy eye in this scenario.

Correct Answer: D

Rationale: The correct answer is D because asking the patient to hold his nose and swallow causes the eustachian tube to open, equalizing pressure in the middle ear. This action will cause the eardrum to bulge slightly outward, making landmarks more visible. Choice A is incorrect as age alone does not preclude the use of this technique. Choice B is incorrect because this technique is not primarily used for assessing otitis media. Choice C is incorrect as it is not specific to upper respiratory infections.

Correct Answer: D

Rationale: The correct answer is D because spirituality involves seeking meaning in one's life, which can provide a sense of purpose and fulfillment. This search is personal and introspective, focusing on individual values and beliefs. A, B, and C are incorrect because spirituality is not solely about belief in a supreme being, adherence to a specific system of beliefs, or the pursuit of life after death. Rather, it is about finding meaning, connection, and inner peace in one's existence.

Correct Answer: C

Rationale: The correct answer is C: Bell's palsy. Bell's palsy is characterized by sudden weakness or paralysis of the facial muscles, resulting in drooping of the face, inability to raise the eyebrow or close the eye, and difficulty with facial expressions and functions like whistling. In this case, the patient's symptoms of left-sided facial paralysis point towards Bell's palsy as the likely diagnosis. Cushing's syndrome (A) is a hormonal disorder, Parkinson's syndrome (B) is a neurodegenerative disorder affecting movement, and a cerebrovascular accident (D) typically presents with more generalized neurological deficits rather than isolated facial paralysis.

Correct Answer: A

Rationale: The correct answer is A: Immobilize the client. This is crucial to prevent further damage to the spinal cord. Moving a client with a suspected spinal cord injury can worsen the injury and lead to permanent damage. Immobilizing the client helps maintain spinal alignment and reduces the risk of paralysis. Providing pain relief (B) and loosening clothing (D) are important but secondary actions. Applying pressure to the chest (C) is not recommended for a suspected spinal cord injury as it can also exacerbate the injury.