Following a motorcycle accident, a 17-year-old man is brought to the ED. What physical assessment findings related to the ear should be reported by the nurse immediately?

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.

Correct Answer: C

Rationale: Step 1: Malnourishment often leads to iron deficiency anemia, causing spoon-shaped nails (koilonychia). Step 2: Koilonychia is a classic sign of chronic malnutrition and iron deficiency. Step 3: Moist lips (A) and pink conjunctivae (B) are not specific to malnourishment. Step 4: Not easily plucked hair (D) is more related to hair health rather than malnutrition.

Correct Answer: C

Rationale: The correct answer is C: Identifying the offending agent, if possible. This is prioritized in contact dermatitis to prevent further exposure and recurrence. By identifying the specific irritant or allergen, the nurse can guide the patient in avoiding it, leading to effective management. Choices A, B, and D are incorrect because while promoting adequate perfusion, safe use of topical antihistamines, and teaching the use of an EpiPen may be relevant in certain situations, they do not directly address the root cause of contact dermatitis, which is exposure to the offending agent.

Correct Answer: C

Rationale: Correct Answer: C - Administering an enema Rationale: Administering an enema is a task that can be safely delegated to nursing assistive personnel (NAP) as it is within their scope of practice and does not require the specialized knowledge and skills of a registered nurse. NAP can be trained to perform enema administration safely and effectively, under the supervision of a nurse. This task involves following a specific procedure and does not require clinical judgment or decision-making. Summary of other choices: A: Performing the first postoperative pouch change - This task involves wound care and assessment, which require the expertise of a registered nurse. B: Maintaining a nasogastric tube - This task involves ongoing assessment, monitoring for complications, and adjustments, which are responsibilities of a registered nurse. D: Digitally removing stool - This task involves invasive procedures and assessment, which are beyond the scope of practice for nursing assistive personnel.

Correct Answer: D

Rationale: Correct Answer: D Rationale: 1. Clear, watery fluid draining from the ear post-accident indicates a possible cerebrospinal fluid (CSF) leak, a serious condition requiring immediate medical attention to prevent complications such as meningitis. 2. CSF leak can result from a basilar skull fracture, common in head injuries like motorcycle accidents. 3. Prompt reporting of this finding by the nurse is crucial for timely intervention and prevention of potential life-threatening complications. Summary: A: Visualizing the malleus during otoscopic examination is normal and not an immediate concern in this scenario. B: A pearly gray tympanic membrane is a normal finding and does not indicate a serious issue post-accident. C: Tenderness in the mastoid area may suggest injury but is not as urgent as clear, watery fluid drainage indicative of a CSF leak.

Correct Answer: B

Rationale: The correct answer is B because in Goodpasture syndrome, the patient's immune system mistakenly targets normal constituents of the body, specifically the basement membrane of the kidneys and lungs. This autoimmune response leads to inflammation and damage in these organs, resulting in respiratory and renal dysfunction. Choice A is incorrect as immune complexes are not the primary mechanism in Goodpasture syndrome. Choice C is incorrect as it refers to T cell-mediated immune responses, which are not the main drivers in this condition. Choice D is incorrect as histamine release and cell lysis are not the main processes involved in Goodpasture syndrome.

Correct Answer: D

Rationale: The correct answer is D. The nurse should arrange for a referral to a rehabilitation facility for vision training. This option directly addresses the patient's inability to read medication bottles accurately due to a vision problem. Vision training can help improve the patient's ability to manage medication independently. A: Asking the social worker to investigate alternative housing arrangements is not relevant to the patient's vision problem affecting medication management. B: Asking the social worker to investigate community support agencies may not directly address the patient's vision issue and medication management. C: Encouraging the patient to explore surgical corrections for the vision problem is not appropriate without considering less invasive options first, such as vision training.

Correct Answer: D

Rationale: Correct Answer: D Rationale: - Giving a change-of-shift report to the oncoming nurse about the patient is an appropriate action that maintains confidentiality by only sharing necessary patient information with authorized healthcare professionals. - A: Writing the patient’s room number and date of birth on a paper for school is a breach of confidentiality as it exposes sensitive patient information to unauthorized individuals. - B: Printing/copying material from the patient’s health record for a graded care plan is also a breach of confidentiality as it involves sharing patient information without proper authorization. - C: Reviewing assigned patient’s record and another unassigned patient’s record is a violation of HIPAA as it involves accessing patient information that is not necessary for the nurse's duties, risking unauthorized disclosure.

Correct Answer: A

Rationale: Correct Answer: A. Provide empathy and encouragement in an effort to foster a positive outlook. Rationale: 1. Empathy and encouragement are essential in establishing rapport and trust with the patient. 2. By fostering a positive outlook, the nurse can help alleviate the patient's anxiety and fears. 3. Encouraging a positive mindset can improve the patient's adherence to treatment. 4. It is important to address the patient's concerns and provide support rather than dismissing them. Summary: B: Telling the patient it is his decision may not address his emotional needs and could lead to further distress. C: Reporting the patient's statement to his support system may breach confidentiality and undermine trust. D: Referring the patient to social work may be premature without first addressing the patient's emotional concerns directly.