A patient complains of leg pain that wakes him at night. He states that he 'has been having problems' with his legs. He has pain in his legs when they are elevated that disappears when he dangles them. He recently noticed 'a sore' on the inner aspect of the right ankle. On the basis of this health history information, the nurse interprets that the patient is most likely experiencing:

Correct Answer: B

Rationale: The correct answer is B) Problems related to arterial insufficiency. In this scenario, the patient's symptoms suggest a possible peripheral arterial disease. The leg pain that is worse at night and improves when dangling the legs is indicative of decreased blood flow to the lower extremities when elevated, a classic symptom of arterial insufficiency. The presence of a sore on the inner aspect of the right ankle further supports this diagnosis as it could be an ulcer due to poor circulation. Option A) Pain related to lymphatic abnormalities is incorrect as the symptoms described are more consistent with arterial rather than lymphatic issues. Option C) Problems related to venous insufficiency typically present with symptoms like edema, varicose veins, and pain that worsens when standing for long periods, which are not evident in this case. Option D) Pain related to musculoskeletal abnormalities does not fit the patient's symptoms of worsening pain with leg elevation and improvement with dangling, along with the presence of an ulcer. Understanding how to differentiate between arterial and venous insufficiency based on patient history is crucial for nurses in assessing and managing patients with potential circulatory issues. Recognizing these subtle differences can lead to timely interventions and prevent further complications.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Cheyne-Stokes respiration. Cheyne-Stokes respiration is a pattern of breathing characterized by alternating periods of deep, rapid breathing followed by shallow, slow breathing and apnea. This pattern is often seen in patients with heart failure, brain injuries, or other conditions affecting the respiratory centers in the brain. The patient's lack of distress despite the abnormal breathing pattern is a key characteristic of Cheyne-Stokes respiration. Option A) Ataxic (Biot's) breathing is characterized by unpredictable irregularity in the depth and rate of breathing, often seen in patients with brain injuries. This does not match the described pattern of deepening and shallowing breaths. Option C) Kussmaul's respiration is deep, rapid, and labored breathing often seen in patients with metabolic acidosis. This pattern does not align with the described breathing pattern in the patient with heart failure. Option D) COPD with prolonged expiration would not present with the described pattern of progressively deeper and shallower breaths followed by apnea. COPD typically presents with prolonged expiration due to air trapping in the lungs. Understanding and recognizing abnormal breathing patterns like Cheyne-Stokes respiration is crucial for healthcare providers to appropriately assess and manage patients with respiratory compromise. By differentiating between these patterns, healthcare professionals can provide timely and effective interventions to support patient respiratory function and overall well-being.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) First-level priority. The reason for this is that the patient's vital signs indicate a critical situation requiring immediate attention. A blood pressure of 74/50 and a heart rate of 148 suggest hypotension and tachycardia, which could indicate a life-threatening condition such as shock. Choosing option B) Second-level priority would be incorrect because vital signs as abnormal as these require immediate intervention to stabilize the patient before addressing other less urgent issues. Option C) Third-level priority is also incorrect because waiting to address the critically abnormal vital signs could result in deterioration of the patient's condition and potential harm. From an educational standpoint, understanding how to prioritize patient care based on the urgency of the situation is crucial in healthcare. Recognizing and responding to abnormal vital signs promptly can make a significant difference in patient outcomes. This question highlights the importance of recognizing first-level priority problems that require immediate action to ensure patient safety and well-being.

Correct Answer: A

Rationale: The correct answer is A) Therapeutic. This statement is considered therapeutic because it provides clear and specific instructions for a patient regarding their pre-medication dietary restrictions. By specifying not to eat or drink anything after midnight except for small sips of water to take morning pills, it ensures that the medication is absorbed optimally and that potential adverse interactions with food are minimized. This guidance promotes the effectiveness and safety of the medication regimen, which is essential in healthcare settings. Option B) Nontherapeutic is incorrect because the statement given is actually therapeutic in nature as it aims to enhance the intended therapeutic outcomes of the medication by controlling the patient's dietary intake. Educational Context: Understanding the distinction between therapeutic and nontherapeutic communication is crucial in healthcare, especially for healthcare professionals such as nurses, doctors, and medical assistants. Therapeutic communication involves providing clear, supportive, and client-centered information that promotes positive health outcomes. Nontherapeutic communication, on the other hand, may hinder effective patient care and can lead to misunderstandings or negative health consequences. In the context of vital signs assessment, clear communication about medication administration instructions, including dietary restrictions, is essential for patient safety and treatment effectiveness. By recognizing and using therapeutic communication techniques, healthcare providers can build trust with patients, enhance adherence to treatment plans, and ultimately improve patient outcomes.

Correct Answer: D

Rationale: In this question, the correct answer is D) Inferior oblique - IV, which is incorrect. The educational rationale behind this lies in the understanding of ocular muscles and their innervation by cranial nerves. The correct pairing for the Inferior oblique muscle is cranial nerve III (oculomotor nerve), not IV (trochlear nerve). The oculomotor nerve innervates most of the extraocular muscles, including the inferior rectus, superior rectus, and inferior oblique muscles. The trochlear nerve primarily innervates the superior oblique muscle. Option A) Medial rectus - III is correct because the medial rectus muscle is innervated by the oculomotor nerve (III). Option B) Lateral rectus - VI is also correct as the lateral rectus muscle is innervated by the abducens nerve (VI), not the trochlear nerve. Option C) Superior oblique - IV is correct because the superior oblique muscle is innervated by the trochlear nerve (IV). Understanding the correct innervation of ocular muscles by cranial nerves is crucial in assessing and diagnosing ocular motor dysfunction and related conditions. This knowledge is essential for healthcare professionals, especially those involved in assessing patients' neurological status and eye movements.