While reviewing the health history of an older adult experiencing hearing loss the nurse notes the patient has had no trauma or loss of balance. What aspect of this patients health history is most likely to be linked to the patients hearing deficit?

Correct Answer: D

Rationale: The correct answer is D: Previous perforation of the eardrum. A perforated eardrum can lead to hearing loss as it affects the transmission of sound waves to the inner ear. This is the most likely link to the patient's hearing deficit as trauma or injury to the eardrum can directly impact hearing. Incorrect choices: A: Recent completion of radiation therapy for treatment of thyroid cancer - Radiation therapy for thyroid cancer typically does not directly affect hearing. B: Routine use of quinine for management of leg cramps - Quinine use is associated with tinnitus (ringing in the ears) but not typically with hearing loss. C: Allergy to hair coloring and hair spray - Allergy to hair products is not directly related to hearing loss. In summary, the most likely cause of the patient's hearing deficit based on the health history provided is the previous perforation of the eardrum, as it directly affects the transmission of sound waves to the inner ear.

Correct Answer: A

Rationale: The correct answer is A: Continuous inflow and outflow of irrigation solution. The first lumen inflates the balloon to secure the catheter in place. The second lumen allows continuous inflow of irrigation solution to prevent clot formation. The third lumen allows continuous outflow to ensure the bladder is continuously irrigated. Choices B, C, and D are incorrect because they do not accurately describe the functions of the three lumens in a transurethral resection of the prostate procedure.

Correct Answer: B

Rationale: The correct answer is B because the patient's inability to count fingers indicates severe visual impairment. Testing hand motion perception is a more appropriate initial assessment for patients with such significant visual losses. This method can differentiate between light perception and no light perception, providing valuable information about the patient's visual acuity. The other choices are incorrect because assessing vision using a Snellen chart (A) requires more visual acuity than just being able to see hand motion. Performing a detailed examination of external eye structures (C) and palpating periocular regions (D) are not relevant for assessing visual acuity and do not provide information on the patient's ability to perceive hand motion.

Correct Answer: B

Rationale: The correct answer is B because an incomplete abortion at 16 weeks may require a D&C to remove remaining tissue to prevent infection and complications. Incomplete abortion means not all fetal tissue has been expelled, posing a risk. Choice A (complete abortion at 8 weeks) does not require a D&C as all tissue is expelled. Choice C (threatened abortion at 6 weeks) does not necessitate immediate intervention. Choice D (incomplete abortion at 10 weeks) is not the best choice as the risk of complications increases with gestational age.

Correct Answer: A

Rationale: The correct order for the massage is to start around the feces (4), then work downwards (1), followed by moving towards the sides (5), then back to the top (2), continuing to the sides again (3), and finally finishing at the top (6). This sequence ensures a thorough and effective massage process. Other choices have different orders that do not follow the logical flow of massaging around the feces and working down as specified in the question.

Correct Answer: C

Rationale: The correct term to describe the belief that the nurse-patient relationship is a partnership where both are equal participants is "Mutuality" (C). This term emphasizes the idea of shared responsibility, respect, and collaboration between the nurse and the patient. It signifies a relationship built on equality and mutual understanding, fostering trust and positive outcomes. Choice A (Critical thinking) involves analyzing and evaluating information, which is essential for decision-making but does not directly reflect the equality and partnership aspect of the nurse-patient relationship. Choice B (Authentic) relates to being genuine and true to oneself, which is important in building trust but does not specifically address the equal participation aspect in the relationship. Choice D (Attend) means to be present or pay attention, which is a fundamental aspect of nursing care but does not capture the full essence of a partnership based on equality and mutual involvement.

Correct Answer: D

Rationale: The correct answer is D: Discuss a referral for hospice care. Hospice care provides specialized care for patients with terminal illnesses, focusing on comfort and quality of life. This option aligns with the patient's wish to die at home and ensures his care needs are met. Hospice care also provides emotional and spiritual support for both the patient and family. A: Discuss a referral for rehabilitation hospital - This option focuses on rehabilitation, which is not suitable for a patient with a terminal illness like extensive stage small-cell lung cancer. B: Panel the patient for a personal care home - Personal care homes may not provide the level of specialized care needed for a terminally ill patient. C: Discuss a referral for acute care - Acute care is more focused on treating acute illnesses and injuries, not providing end-of-life care for a patient with a terminal illness.

Correct Answer: A

Rationale: The correct answer is A: HIV encephalopathy. This condition, also known as AIDS dementia complex, is characterized by progressive decline in cognitive, behavioral, and motor functions due to HIV affecting the brain. The onset of these symptoms in the patient is indicative of HIV encephalopathy. Explanation for why other choices are incorrect: B: B-cell lymphoma is a type of cancer that can occur in patients with AIDS, but it typically presents with symptoms related to lymph nodes or other organs, not cognitive decline. C: Kaposis sarcoma is a type of cancer caused by the human herpesvirus 8, and it typically presents with skin lesions or internal organ involvement, not cognitive decline. D: Wasting syndrome is characterized by severe weight loss, weakness, and loss of muscle mass, but it does not directly cause cognitive, behavioral, and motor decline as seen in HIV encephalopathy.

Correct Answer: D

Rationale: The correct answer is D, combining multiple objective measures with subjective measures. This approach provides a comprehensive assessment of the patient's nutritional status by incorporating both quantitative data (objective measures) such as weight, BMI, and laboratory values, as well as qualitative information (subjective measures) like dietary history and appetite changes. By combining these measures, the nurse can obtain a more holistic view of the patient's nutritional status, allowing for better identification of nutritional deficiencies or excesses. This method enhances the accuracy and reliability of the assessment compared to relying solely on one type of measure. Choice A is incorrect because nutritional assessment is crucial even in the presence of chronic disease to address potential malnutrition risks. Choice B is incorrect as the Mini Nutritional Assessment is not intended for pediatric patients but for adults. Choice C is incorrect as using a single tool may not capture the full complexity of the patient's nutritional status.