The nurse is discussing the results of a patients diagnostic testing with the nurse practitioner. What Weber test result would indicate the presence of a sensorineural loss?

Correct Answer: C

Rationale: The correct answer is C because in sensorineural hearing loss, the sound is heard better in the ear with poorer hearing due to damage to the inner ear or auditory nerve. This is because the brain perceives the sound as louder in the affected ear to compensate for the hearing loss. Choice A is incorrect as it describes the result for conductive hearing loss. Choice B is incorrect as it indicates normal hearing. Choice D is incorrect as it describes the result for a lateralizing conductive hearing loss.

Correct Answer: C

Rationale: The correct answer is C: The patient's vomiting is unrelated to food intake. In the context of a brain tumor, vomiting that is not related to food intake can indicate increased intracranial pressure affecting the brain's vomiting center. This is known as projectile vomiting. A: Vomiting accompanied by epistaxis (nosebleeds) is more indicative of other conditions like hypertension or nasal issues, not necessarily specific to a brain tumor. B: Vomiting not relieving nausea can be seen in various conditions affecting the gastrointestinal system, not specifically brain tumors. D: Blood-tinged emesis can suggest gastrointestinal bleeding or other issues, but it's not a specific characteristic of vomiting associated with brain tumors.

Correct Answer: B

Rationale: The correct answer is B: Circumcision. Paraphimosis occurs when the foreskin is retracted behind the glans and cannot be returned to its original position. Once the inflammation and edema subside, circumcision is typically indicated to prevent recurrence. This procedure removes the foreskin, reducing the risk of future paraphimosis episodes. Needle aspiration of the corpus cavernosum (A) is not indicated for paraphimosis. Abstinence from sexual activity for 6 weeks (C) is not a standard treatment for paraphimosis. Administration of vardenafil (D) is used for erectile dysfunction and not indicated for paraphimosis.

Correct Answer: B

Rationale: The correct answer is B: Focusing the patient's immune system exclusively on the tumor. Biologic response modifiers (BRMs) work by enhancing the body's natural defenses to target and attack cancer cells specifically. This approach helps the immune system to recognize and destroy cancer cells while minimizing harm to normal cells. A: Promoting the synthesis and release of leukocytes - This is not the primary mechanism of action for BRMs. While leukocytes play a role in the immune response, BRMs target the immune system's response to tumors. C: Potentiating the effects of chemotherapeutic agents and radiation therapy - While some BRMs may be used in combination with these treatments, their primary mode of action is not to enhance the effects of chemotherapy or radiation therapy. D: Altering the immunologic relationship between the tumor and the patient - This choice is too broad and vague. BRMs specifically aim to direct the immune response towards targeting the tumor cells, rather than altering the overall immunologic relationship

Correct Answer: C

Rationale: The correct answer is C: Whisper test. The nurse can perform a whisper test by whispering a series of numbers or words at a distance from the child to see if they can repeat them accurately. If the child struggles to hear and repeat the whispered words, it could indicate hearing loss. Rationale: A: Audiometry is a comprehensive hearing test that measures the range and sensitivity of hearing, not suitable for a quick preliminary assessment. B: Rinne test and D: Weber test are both tuning fork tests used to assess conductive and sensorineural hearing loss, not ideal for a quick initial screening of hearing loss. Summary: The Whisper test is the most suitable choice as it provides a quick and simple way to preliminarily assess hearing loss by evaluating the child's ability to hear and repeat whispered sounds accurately.

Correct Answer: A

Rationale: The correct answer is A: Assess for bladder distention. Oliguria indicates decreased urine output, which could be due to urinary retention. Assessing for bladder distention helps identify the underlying cause. Requesting diuretics (B) without assessing first is premature. Increasing IV fluid rate (C) may worsen the situation if there is urinary retention. Encouraging caffeinated beverages (D) is not appropriate as they can worsen dehydration.

Correct Answer: D

Rationale: The correct answer is D because it provides an accurate and comprehensive response to the pregnant patient's question about the risk of her baby being born with HIV. Here's the step-by-step rationale: 1. Option D acknowledges the possibility of the baby contracting HIV at different stages: before, during, or after delivery. This covers all potential scenarios and educates the patient about the risks. 2. By mentioning the different possible transmission times, the nurse highlights the importance of proper prenatal care, delivery planning, and postnatal care to minimize the risk of HIV transmission to the baby. 3. This response empowers the patient with knowledge about the potential risks and emphasizes the importance of seeking appropriate medical interventions to prevent mother-to-child transmission of HIV. 4. In contrast, options A, B, and C provide less informative or inaccurate responses that do not address the patient's concerns adequately, making them incorrect choices. In summary, option D is the best response as it educates the patient about the risks of HIV transmission

Correct Answer: B

Rationale: The correct answer is B: Jejunostomy tube. This tube is chosen because the patient has a history of aspiration pneumonia, which puts them at risk for aspiration if feeds are administered into the stomach. By administering feeds through a jejunostomy tube, the risk of aspiration pneumonia is minimized as the feed bypasses the stomach. Nasogastric tube (A) and Nasointestinal tube (C) would still deliver feeds to the stomach, increasing the risk of aspiration. PEG tube (D) is also not ideal as it delivers feeds directly to the stomach, which is not recommended for patients at risk for aspiration.

Correct Answer: C

Rationale: The correct answer is C because providing individualized care is a fundamental aspect of cultural competence. This means tailoring care to meet the unique cultural, social, and personal needs of each patient. It involves understanding and respecting a patient's beliefs, values, and practices. Explanation: A. Providing care to transgender patients is important, but it is not the primary goal of cultural competence. B. Restoring relationships is beneficial but may not directly address cultural competence. D. Providing care to surgical patients is a common nursing duty but does not specifically relate to cultural competence.