Foundations and Adult Health Nursing Study Guide Answers

Correct Answer: D

Rationale: Pelvic ultrasound can detect fetal congenital defects, placenta previa, and fetal lung maturity.

Correct Answer: A

Rationale: The presentation of a palpable, non-tender mass in the right neck, just below the angle of the mandible, along with ultrasound imaging findings of a well-defined, hypoechoic lesion with cystic components, is classic for a branchial cleft cyst. Branchial cleft cysts are congenital anomalies that arise from remnants of the branchial clefts or pouches during embryonic development. They are typically located along the anterior border of the sternocleidomastoid muscle, just below the mandible. Ultrasound imaging often shows a cystic lesion with well-defined borders and hypoechoic content, which is consistent with the described findings. Thyroglossal duct cysts usually present as midline neck masses that move with swallowing or tongue protrusion, not in the location described in the scenario. Lymphadenopathy would present as enlarged lymph nodes that may be tender and associated with systemic symptoms.

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: The nurse should obtain interpreter services or language assistance as needed to ensure effective communication with a patient who has limited English proficiency. Using an interpreter will facilitate clear and accurate communication between the nurse and the patient, enabling the patient to fully understand their care, treatment, and any instructions provided. Speaking loudly or slowly, using medical jargon, or ignoring the language barriers are not effective strategies for communicating with a patient who has limited English proficiency. Utilizing interpreter services demonstrates respect for the patient's language and cultural needs, which is essential for providing high-quality care.

Correct Answer: C

Rationale: Verbal communication involves the use of words and language to convey information. The content refers to the actual words and messages being communicated. In verbal communication with your patient, the content of what you say is key to ensuring effective communication that is clear, accurate, and easily understood. Therefore, the use of literal words when speaking to your patient embodies the content of your communication.