Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: B

Rationale: Ramsay Hunt syndrome is caused by the varicella-zoster virus affecting the geniculate ganglion, leading to a triad of symptoms known as the Hunt syndrome: facial paralysis, ear pain, and a vesicular rash in the ear or palate. The facial paralysis in Ramsay Hunt syndrome is usually peripheral, similar to Bell's palsy, but may be more severe. In addition to facial paralysis, the patient may have the inability to close the eye on the affected side (lagophthalmos) and loss of taste sensation on the anterior two-thirds of the tongue due to involvement of the chorda tympani nerve. This differentiation is important to consider in the context of our patient's presentation.

Correct Answer: C

Rationale: When a patient is at risk of falls due to an impaired gait, a physical therapist would be the most appropriate member of the multidisciplinary team for the nurse to collaborate with. Physical therapists specialize in improving mobility, balance, and coordination through exercises, gait training, and other interventions. They can assess the patient's gait pattern, strength, and balance, and develop a personalized plan to address the impairments contributing to the fall risk. By working closely with a physical therapist, the nurse can help the patient improve their gait and reduce the risk of falls, ultimately promoting safety and independence.

Correct Answer: A

Rationale: The patient's symptoms of fever, chills, headache, and myalgia after returning from sub-Saharan Africa are consistent with malaria. Intraerythrocytic ring forms and trophozoites observed on blood smear examination are characteristic of Plasmodium species, particularly Plasmodium falciparum, which is the most common and deadliest species causing malaria in sub-Saharan Africa. Plasmodium falciparum can lead to severe complications, such as cerebral malaria, if not promptly treated. Trypanosoma cruzi causes Chagas disease, not malaria. Borrelia burgdorferi is responsible for Lyme disease, which typically presents with a different set of symptoms like erythema migrans rash. Leishmania donovani causes visceral leishmaniasis, not malaria.

Correct Answer: B

Rationale: Encouraging the patient to practice controlled coughing techniques would be the most appropriate intervention to address the symptoms of chronic cough and excessive sputum production in a patient with end-stage COPD receiving palliative care. Controlled coughing techniques can help the patient effectively clear respiratory secretions and improve airway clearance without the need for additional medications or interventions. This approach focuses on optimizing the patient's ability to manage their symptoms and maintain comfort, which aligns with the goals of palliative care. Administering bronchodilator medications, prescribing mucolytic medications, or referring the patient to a respiratory therapist for breathing exercises may have limited effectiveness in this advanced stage of the disease, and controlled coughing techniques would be a more practical and patient-centered approach to symptom management.

Correct Answer: A

Rationale: Given the sudden-onset severe scrotal pain, swelling, and erythema, along with the physical examination findings of a tender, swollen, and high-riding testicle, the most likely diagnosis is testicular torsion. Testicular torsion occurs when the spermatic cord twists, leading to compromised blood flow to the testicle, causing ischemia and severe pain. It is considered a surgical emergency that requires prompt diagnosis and intervention to salvage the affected testicle. Prompt surgical detorsion is necessary to prevent irreversible testicular damage. While epididymitis, testicular trauma, and testicular tumors can also present with scrotal pain and swelling, the presence of a high-riding testicle in this context is highly suggestive of testicular torsion.