ATI RN
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Question 1 of 5
The nurse is assessing a 16-year-old patient with head injuries from a recent motor vehicle accident. Which of the following statements indicates the most important reason for assessing for any drainage from the canal?
Correct Answer: B
Rationale: Correct Answer: B Rationale: 1. Bloody or clear watery drainage can indicate a basal skull fracture. 2. Basal skull fractures can cause cerebrospinal fluid leakage, leading to clear watery drainage. 3. Blood in the ear canal can suggest a temporal bone fracture. 4. Assessing for drainage helps identify potential serious head injuries. Summary: A. Incorrect. Purulent drainage indicates infection, not related to head injuries. C. Incorrect. Increased cerumen is not the priority in assessing head injuries. D. Incorrect. Foreign bodies in the canal are not the primary concern in this scenario.
Question 2 of 5
The projections in the nasal cavity that increase the surface area are called the:
Correct Answer: C
Rationale: The correct answer is C: turbinates. Turbinates are bony projections in the nasal cavity that increase the surface area for the warming, humidifying, and filtering of inhaled air. Meatus (A) refers to the passages in the nasal cavity, not the projections. Septum (B) is the partition between the nostrils, not the projections. Kiesselbach's plexus (D) is a collection of blood vessels in the nasal septum, not the projections that increase surface area.
Question 3 of 5
A 19-year-old community college student is brought to the emergency department with a severe headache he describes as"like nothing I've ever had before." His temperature is 40°C, and his neck is stiff. What do these signs and symptoms suggest?
Correct Answer: D
Rationale: The signs and symptoms - severe headache, high fever, and neck stiffness - in a young adult point towards meningeal inflammation. The combination of these symptoms is indicative of a potential infection or inflammation of the meninges, the protective membranes surrounding the brain and spinal cord. The presence of fever and neck stiffness, in addition to the severe headache, raises concern for meningitis, an infection of the meninges. This is a medical emergency that requires prompt evaluation and treatment. Other choices are incorrect because: A: Head injury usually presents with a history of trauma, which is not mentioned in the scenario. B: Cluster headaches typically do not present with fever and neck stiffness. C: Migraine headaches do not typically cause such high fever and neck stiffness.
Question 4 of 5
The nurse is taking history from a patient who may have a perforated eardrum. What would be an important question in this situation?
Correct Answer: D
Rationale: The correct answer is D because it directly addresses the concern of a possible perforated eardrum by inquiring about the relationship between ear pain and discharge. This is crucial in assessing the severity of the condition. Choice A is incorrect as it focuses on subjective symptoms not specific to a perforated eardrum. Choice B is irrelevant as it doesn't pertain to the immediate concern. Choice C is also incorrect as it doesn't target the current issue of a potential perforated eardrum. Asking about ear pain and discharge helps determine the likelihood of a perforated eardrum and guides further assessment and care.
Question 5 of 5
The nurse is assessing a patient with a history of intravenous drug abuse. While assessing his mouth, the nurse notices a dark red confluent macule on the hard palate. This could be an early sign of:
Correct Answer: A
Rationale: The correct answer is A: acquired immunodeficiency syndrome (AIDS). The dark red confluent macule on the hard palate is known as Kaposi's sarcoma, a common manifestation of AIDS. This lesion is caused by Human Herpesvirus 8 and is often seen in patients with compromised immune systems. Measles (B) typically presents with a rash, not a dark red macule. Leukemia (C) does not typically manifest as a dark red macule in the mouth. Carcinoma (D) refers to cancer and would present differently than Kaposi's sarcoma. In summary, the presence of a dark red confluent macule on the hard palate in a patient with a history of intravenous drug abuse is highly suggestive of AIDS, specifically Kaposi's sarcoma.
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