Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: Acute otitis media is the most likely condition responsible for this presentation. The sudden onset of severe, unilateral ear pain, diminished hearing, and purulent otorrhea are classic symptoms of acute otitis media. Otoscopic examination revealing a bulging, erythematous tympanic membrane with obscured landmarks further supports the diagnosis. The bulging of the tympanic membrane is due to the accumulation of fluid and pus behind it, causing the characteristic appearance. Treatment typically involves antibiotics to help clear the infection and relieve symptoms. If left untreated, acute otitis media can lead to complications such as perforation of the eardrum or mastoiditis.

Correct Answer: A

Rationale: Of the options provided, documenting objective, observable findings such as large bruises on the thigh upon assessment is the most defensible entry in court. This type of entry is based on the nurse's direct observation and assessment of the patient's physical condition, which can be corroborated by other healthcare providers or evidence. It provides clear, factual information without making assumptions or subjective judgments. In court, this type of documentation can help support the nurse's credibility and reliability as a witness.

Correct Answer: A

Rationale: In a community clinic providing primary care for patients, the most common healthcare professional who manages patient care is a physician. Physicians, also known as doctors, are trained and licensed to diagnose and treat a wide range of medical conditions. They are responsible for conducting exams, prescribing medications, ordering tests, and developing treatment plans for patients. While other healthcare professionals such as nurses, midwives, and barangay health workers also play important roles in providing care, physicians typically lead the team, make critical decisions, and provide overall management of patient care in a primary care setting like a community clinic.

Correct Answer: A

Rationale: The patient's presentation of sudden-onset, painless vision loss in the right eye, along with a cherry-red spot at the macula and attenuated retinal vessels, is classic for central retinal artery occlusion (CRAO). In CRAO, there is a sudden blockage of the central retinal artery, leading to ischemia of the retina. The cherry-red spot represents the preserved choroid blood flow against the ischemic retina. The attenuated retinal vessels are a result of decreased blood flow in the retinal circulation. This condition is considered an ophthalmic emergency and requires immediate evaluation and management to prevent permanent vision loss.

Correct Answer: A

Rationale: In a patient with acute myocardial infarction (MI) complicated by cardiogenic shock, the primary intervention to manage shock is emergent percutaneous coronary intervention (PCI). PCI is a procedure performed to restore blood flow in an occluded coronary artery that is causing the MI. By opening up the blocked artery and restoring blood flow to the heart muscle, PCI can help reduce myocardial damage, improve cardiac function, and stabilize the patient's condition. Prompt reperfusion via PCI is crucial in the setting of cardiogenic shock to improve survival outcomes and reduce the risk of further complications. Administering inotropic medications, initiating therapeutic hypothermia, or recommending anticoagulant therapy may be components of management in specific cases but are not the primary intervention for managing shock in a patient with acute MI and cardiogenic shock.