The following data collection findings could indicate to the nurse that the patient has a hearing loss, EXCEPT:

Correct Answer: A

Rationale: A relaxed face during conversation is not typically indicative of hearing loss. In fact, individuals with hearing loss may exhibit signs such as speaking loudly (Choice B), turning toward the person speaking (Choice C), and feeling withdrawn (Choice D) due to difficulty in hearing and understanding conversations. The act of speaking loudly may be an attempt to compensate for the perceived hearing loss, while turning toward the speaker is a common strategy to better hear and lip-read. Withdrawal can result from the frustration and isolation caused by the inability to fully engage in conversations. Ultimately, a relaxed face during conversation is less likely to be a red flag for hearing loss compared to the other choices provided.

Correct Answer: D

Rationale: In this situation, the client is experiencing dyspnea, audible wheezing, and decreased oxygen saturation, indicating the presence of respiratory distress, likely due to bronchoconstriction. These are classic symptoms of an acute asthma exacerbation or an obstructive respiratory condition. Beta2 agonists, such as albuterol, are bronchodilators that work by relaxing the muscles in the airways, relieving bronchoconstriction and improving airflow. Administering a beta2 agonist promptly is crucial to provide relief and improve the client's respiratory status. Antibiotics, antivirals, and beta-blockers are not appropriate treatments for acute bronchoconstriction or asthma exacerbation.

Correct Answer: B

Rationale: Giving Mr. Franco frequent mouth care is important to remove dried blood when the tongue is bitten during a seizure. Seizures can cause involuntary biting of the tongue, leading to the accumulation of dried blood in the mouth. If this blood is not removed promptly, it can result in discomfort, infection, and potential complications. Regular oral care helps maintain oral hygiene and prevents any issues related to oral trauma during seizures, promoting overall health and well-being for the patient.

Correct Answer: D

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.

Correct Answer: C

Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.

Correct Answer: D

Rationale: Patients who have undergone splenectomy are at risk for overwhelming postsplenectomy infection (OPSI) due to the absence of a functioning spleen, which is important in fighting certain types of infections, especially those caused by encapsulated bacteria such as Streptococcus pneumoniae. Symptoms of OPSI can include fever, chills, weakness, and rapid breathing. Fever is a significant sign that alerts the nurse to the possibility of OPSI in a post-splenectomy patient, as it may indicate an infection that the body is struggling to fight without the spleen's immune support. This is a crucial symptom to monitor and act upon promptly to prevent serious complications in these individuals.

Correct Answer: C

Rationale: During the surgical procedure, the circulating nurse, scrub nurse, and nurse first assistant are responsible for keeping track of all instruments, needles, and sponges used. As the surgical incision is being closed, the circulating nurse and the scrub nurse/nurse first assistant conduct a final count of all needles, sponges, and instruments to ensure that nothing is accidentally left inside the patient's body. This is a critical step in preventing retained surgical items (RSI), which can lead to serious complications for the patient. It is part of the standard protocol in the operating room to have these specific personnel take charge of counting and verifying all items before the procedure is concluded.

Correct Answer: B

Rationale: Danazol (Danocrine) is a synthetic androgen that is used to treat conditions such as fibrocystic breast disease. One of the known adverse effects of danazol is the development of amenorrhea, which refers to the absence of menstrual periods. This occurs because danazol suppresses ovarian function by inhibiting the release of gonadotropins, leading to decreased production of estrogen and progesterone. Amenorrhea associated with danazol use is typically reversible upon discontinuation of the medication. Nausea, confusion, and hypotension are not common adverse reactions associated with danazol use for fibrocystic breast disease.

Correct Answer: B

Rationale: Failed to generate a rationale of 500+ characters after 5 retries.