The nurse is assessing a patient with multiple sclerosis who is demonstrating involuntary, rhythmic eye movements. What term will the nurse use when documenting these eye movements?

Correct Answer: C

Rationale: The correct term for the involuntary, rhythmic eye movements seen in the patient with multiple sclerosis is nystagmus. Nystagmus is a condition characterized by repetitive, uncontrolled eye movements that can be horizontal, vertical, or rotary. In multiple sclerosis, nystagmus can occur due to damage to the nerves that control eye movement. Vertigo (choice A) is a sensation of spinning or dizziness, not related to eye movements. Tinnitus (choice B) is a perception of noise or ringing in the ears. Astigmatism (choice D) is a refractive error of the eye, not related to involuntary eye movements.

Correct Answer: C

Rationale: The correct answer is C: Sensorineural hearing loss. This type of hearing loss is caused by damage to the inner ear or auditory nerve (cranial nerve VIII). Exostoses (A) are bony growths in the ear canal, not related to cranial nerve VIII. Otalgia (B) refers to ear pain, not hearing loss. Presbycusis (D) is age-related hearing loss, not specifically related to damage of the end organ for hearing or cranial nerve VIII. Therefore, C is the most appropriate term to describe the given condition.

Correct Answer: A

Rationale: The correct answer is A: Rubella. Rubella infection during pregnancy can lead to congenital rubella syndrome, which includes bilateral cataracts as a characteristic feature. Rubella virus can cross the placenta and affect the developing fetus. Cytomegalovirus (CMV) can also cause congenital cataracts, but rubella is more commonly associated with this abnormality. Syphilis can cause other congenital abnormalities but not bilateral cataracts. HIV does not typically lead to bilateral cataracts in newborns.

Correct Answer: C

Rationale: The correct answer is C: Evidence of a more advanced lesion. A stoney hardening in the posterior lobe of the prostate gland that is not mobile is indicative of a more advanced lesion, such as prostate cancer. This finding suggests that the lesion has progressed beyond the early stages. In early prostate cancer, the prostate gland may feel firm but not stoney hard, and the lesion is usually mobile. Metastatic disease would involve spread of the cancer to other parts of the body, which is not evident from the DRE alone. A normal finding would not present as stoney hardening and lack of mobility in the prostate gland during a DRE.

Correct Answer: A

Rationale: The correct answer is A because a protein level of 2 mg/100 mL in urine indicates proteinuria, which can be a sign of kidney dysfunction or other underlying health issues. The nurse should follow up to assess further for possible kidney disease or other conditions. Choice B is not a cause for concern as a urine output of 80 mL/hr is within the normal range. Choice C indicates concentrated urine, which may be due to dehydration but does not necessarily require immediate follow-up. Choice D is within the normal range for urine pH and does not typically warrant immediate follow-up.

Correct Answer: C

Rationale: The correct answer is C because the patient's affect, which refers to their emotional expression, is inappropriate. The patient is smiling while expressing anger, which is a contradiction. This inconsistency indicates a possible underlying issue such as emotional distress or confusion. Choice A is incorrect because the issue is not about the patient's understanding of the term "cough and deep breathe." Choice B is incorrect as there is no mention of personal space violation. Choice D is incorrect as the issue is not related to the patient's vocabulary but rather their emotional expression.

Correct Answer: B

Rationale: The correct answer is B: There is an increased incidence of disease. Low-income immigrants often face barriers to healthcare access, leading to higher rates of undiagnosed and untreated health conditions. This information is crucial for the nurse to plan appropriate care interventions. Incorrect choices: A: Decreased frequency of morbidity is not accurate as low-income immigrants may experience higher rates of illness due to lack of resources. C: Increased level of health is unlikely in this population due to socioeconomic factors affecting health outcomes. D: Decreased mortality rate is not supported as low-income immigrants may have higher mortality rates due to limited access to healthcare.

Correct Answer: C

Rationale: The correct answer is C: Avoid lifting objects heavier than 10 pounds. This recommendation is crucial post-mastectomy as it helps prevent lymphedema and promotes healing without causing strain on the surgical site. Lifting heavy objects can lead to complications such as lymphedema or disruption of the healing process. Options A, B, and D are incorrect as avoiding exercise of the arm for 2 months may lead to stiffness and reduced range of motion, keeping cuticles clipped neatly does not directly affect rehabilitation, and using a sling is not necessary unless specifically advised by the healthcare provider.

Correct Answer: A

Rationale: The correct answer is A: Preparation of nutritious meals and avoidance of contraindicated foods. After mastoid surgery, proper nutrition is crucial for healing and recovery. Nutritious meals support the immune system and aid in tissue repair. Avoiding contraindicated foods, such as those that may cause inflammation or interfere with medications, is essential for the patient's well-being. Choices B, C, and D are not the primary focus of home care after mastoid surgery. While rest, adaptation to hearing loss, and assistance with ambulation are important, they are secondary to ensuring proper nutrition for optimal recovery in this case.