Foundations and Adult Health Nursing Test Bank

Correct Answer: B

Rationale: The primary purpose of a cervical collar in the management of trauma patients is to immobilize the cervical spine. This is crucial in cases of suspected cervical spine injury to prevent any further damage and to maintain spinal stability. By providing support and restricting movement in the cervical spine region, a cervical collar helps prevent potential spinal cord injuries and associated neurological deficits. It is essential to immobilize the cervical spine until a thorough evaluation can be carried out to determine the extent of injury, as any movement of the spine during this period can worsen the damage.

Correct Answer: C

Rationale: The suicide of her mother is the most probable historical data that led to post-traumatic stress disorder. Experiencing the suicide of a close family member, especially a parent, can be an extremely traumatic event that can have long-lasting psychological effects. Witnessing or dealing with such a tragic loss can lead to feelings of helplessness, depression, guilt, and intense emotional distress, all of which are common in individuals with post-traumatic stress disorder (PTSD). This significant and distressing event could have a profound impact on the individual's mental health and well-being, contributing to the development of PTSD symptoms such as intrusive memories, avoidance behaviors, negative mood alterations, and changes in arousal or reactivity.

Correct Answer: A

Rationale: Troponin is the most specific cardiac biomarker for myocardial injury. Troponin I and Troponin T are proteins released into the bloodstream when there is damage to the heart muscle, making them highly indicative of myocardial infarction. Troponin levels rise within a few hours of cardiac injury, peak within 24-48 hours, and can remain elevated for up to 2 weeks. Troponin is considered the gold standard biomarker for the diagnosis of acute myocardial infarction due to its high specificity and sensitivity for cardiac injury. In contrast, Creatine kinase-MB (CK-MB) and myoglobin are also used in diagnosing myocardial infarction but are less specific than troponin. Brain natriuretic peptide (BNP) is primarily used in heart failure diagnosis and management, and its levels are not specific to myocardial injury.

Correct Answer: A

Rationale: This scenario falls under the category of invasion of privacy. Invasion of privacy occurs when a person's private information or images are shared or used without their consent, leading to an intrusion of their private life. In this case, Kris, as a hospitalized movie star, had her picture taken without permission by the nursing assistant, which was later sold to a local newspaper. Kris has a right to privacy, especially during a vulnerable time like being hospitalized, and the nursing assistant violated that right by taking and selling her picture without consent. This action constitutes an invasion of privacy.

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.