When a patient is diagnosed to have pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would be ______.

Correct Answer: B

Rationale: When a patient is diagnosed with pneumonia, the breath sounds detected by the nurse on auscultation of the affected area would typically include fine crackles. Fine crackles are discontinuous, high-pitched crackling or rattling sounds heard during inspiration that indicate the presence of fluid in the small airways or alveoli. These crackles are caused by the movement of secretions or exudate within the bronchioles or alveoli, which is a common characteristic of pneumonia. Wheezing sounds are usually associated with conditions such as asthma, bronchitis, or COPD and are caused by narrowed airways. Stridor is a high-pitched, crowing sound that typically indicates an obstruction in the upper airway and is often heard in cases of laryngeal inflammation or foreign body aspiration. Deep and low-pitched breath sounds are more characteristic of conditions like chronic bronchitis.

Correct Answer: B

Rationale: In preparing for a possible earthquake as part of Safe Practice Environment (SPE) standards, the QA team should prioritize attention on Electrical wires (I) and Combustible materials (II).

Correct Answer: C

Rationale: The primary nursing care delivery model is represented by option C, where the nurse performs all tasks needed by the individual patient to optimize health. In this model, the nurse is responsible for coordinating and providing comprehensive care to a specific group of patients throughout their stay. The primary nurse establishes a close relationship with the patient and takes accountability for their care, ensuring continuity, communication, and personalized attention. This approach emphasizes the importance of the nurse-patient relationship and holistic care delivery, which can lead to improved patient outcomes and satisfaction.

Correct Answer: C

Rationale: The correct next step after positioning the child is to drop the medicine into the ear canal. This is typically the next step in administering ear drops for a child. The cleaning and positioning steps are to prepare the ear for receiving the medication. Dropping the medicine into the ear canal ensures that the medication can reach the affected area effectively. Once the medicine is dropped into the ear canal, it is important to follow any additional instructions provided by the healthcare provider regarding keeping the ear in a certain position or any other post-administration care steps.

Correct Answer: A

Rationale: Estrogen exerts negative feedback on the hypothalamus by inhibiting the release of GnRH (Gonadotropin-Releasing Hormone). GnRH plays a crucial role in the regulation of follicle-stimulating hormone (FSH) and luteinizing hormone (LH) production from the pituitary gland. By inhibiting the release of GnRH, estrogen ultimately leads to a decrease in FSH and LH levels. This process helps to suppress the maturation of the egg and ovulation, providing contraceptive effects.

Correct Answer: B

Rationale: Battery in the context of healthcare refers to the intentional and unauthorized touching of a patient. By applying a body restraint without a doctor's order, Nurse Edna has potentially committed battery against the patient. It is important for healthcare providers to obtain proper authorization before implementing any physical restraints on a patient to avoid legal liabilities such as battery.

Correct Answer: C

Rationale: The clinical presentation of fever, malaise, maculopapular rash starting on the face and spreading to the trunk and extremities, along with leukopenia and thrombocytopenia, is highly suggestive of Rocky Mountain spotted fever (RMSF) caused by Rickettsia rickettsii. RMSF is a tick-borne illness transmitted by the American dog tick, Rocky Mountain wood tick, and brown dog tick. The constellation of symptoms described aligns well with the typical presentation of RMSF. Borrelia burgdorferi causes Lyme disease, which presents with erythema migrans but does not typically cause leukopenia or thrombocytopenia. Plasmodium falciparum is the causative agent of severe malaria and would present with symptoms such as cyclic fevers, anemia, and jaundice but not the described rash distribution.

Correct Answer: B

Rationale: T cell exhaustion is a state of T cell dysfunction that arises during chronic viral infections or cancer. In the case of a chronic viral infection, the persistent exposure to viral antigens leads to continuous stimulation of CD8+ cytotoxic T cells. Over time, this sustained stimulation can lead to T cell exhaustion, characterized by the upregulation of inhibitory receptors, impaired effector functions, and reduced proliferative capacity. As a result, despite the elevated levels of CD8+ T cells in the blood, their function may be compromised, ultimately impacting the immune response against the viral infection. In contrast, activation-induced cell death (AICD) may contribute to T cell loss during chronic infections but would not explain the persistently elevated CD8+ T cell levels. Thymic involution refers to the age-related decline in thymus function, which is not directly related to the observed increase in CD8+ T cells. Antigenic

Correct Answer: C

Rationale: The nurse should always keep Tensilon (Edrophonium) at the bedside of a client with myasthenia gravis. Tensilon is a fast-acting cholinesterase inhibitor that can be used for the diagnosis and emergency treatment of myasthenia crisis. It helps improve muscle strength temporarily by increasing the levels of acetylcholine at the neuromuscular junction. Administering Tensilon can help differentiate between a myasthenic crisis (marked improvement in muscle strength) and a cholinergic crisis (no improvement or worsening of muscle weakness). Keeping Tensilon at the bedside allows for prompt administration in case of a myasthenic crisis.