A patient has been diagnosed with venous stasis. Which of these findings would the nurse most likely observe?

Correct Answer: D

Rationale: The correct answer is D because brownish discoloration to the skin of the lower leg is a classic sign of venous stasis due to hemosiderin deposition from chronic venous insufficiency. This occurs as a result of red blood cell breakdown and leaking into the tissues. The other choices are incorrect because: A) Unilateral cool foot is more indicative of arterial insufficiency, B) Thin, shiny, atrophic skin is characteristic of arterial insufficiency or aging, and C) Pallor of the toes and cyanosis of the nail beds are signs of arterial insufficiency as well.

Correct Answer: B

Rationale: The correct answer is B: Flight of ideas. Flight of ideas is a symptom commonly seen in manic episodes, where thoughts are rapidly moving from one idea to another, making it challenging to follow the conversation. In this scenario, the patient's fast and erratic speech pattern with disjointed ideas aligns with the classic presentation of flight of ideas. Derailment (A) refers to a sudden shift in the topic without any apparent connection, which is not the case here. Circumstantiality (C) involves providing unnecessary detail before reaching the main point, which does not fit the description provided. Incoherence (D) refers to speech that is illogical and incomprehensible, which is not the primary feature presented in the scenario.

Correct Answer: A

Rationale: The correct answer is A because evidence-based nursing practice involves combining clinical expertise with the use of nursing research to provide the best care for patients while considering the patient's values and circumstances. This approach ensures that nursing interventions are based on the best available evidence, tailored to individual patient needs, and aligned with patient preferences. It emphasizes the integration of research evidence, clinical expertise, and patient values to optimize patient outcomes. Choice B is incorrect because evidence-based nursing practice involves a comprehensive review of multiple research studies, not just one or two articles. Choice C is incorrect because completing a literature search is just one step in the evidence-based practice process, which also involves critically appraising and applying the evidence to patient care. Choice D is incorrect because evidence-based practice focuses on using research evidence, not value-based resources, to guide nursing actions.

Correct Answer: D

Rationale: The correct answer is D because trigger finger can be caused by Dupuytren's disease, ganglion of the tendon sheath, or rheumatoid arthritis. Dupuytren's disease can lead to the formation of nodules in the palm that can affect finger movement. Ganglion of the tendon sheath can cause tendon swelling and lead to triggering of the finger. Rheumatoid arthritis can result in inflammation of the tendon sheaths, causing trigger finger. Therefore, all of the above conditions are part of the differential diagnosis for trigger finger. Choices A, B, and C are incorrect individually because trigger finger can be associated with each condition separately.

Correct Answer: C

Rationale: The true leg length should be measured between the ASIS (anterior superior iliac spine) and the medial malleolus. This is because the ASIS is a prominent bony landmark on the pelvis, representing the top of the femur, and the medial malleolus is the bony prominence on the inner side of the ankle, representing the bottom of the tibia. Measuring between these points provides an accurate representation of the actual length of the leg. Choice A (Greater trochanter to lateral malleolus) is incorrect because the greater trochanter is not the starting point for measuring leg length. Choice B (Umbilicus and lateral malleolus) is incorrect as the umbilicus is not a reliable reference point for leg length measurement. Choice D (Anterior inferior iliac spine and medial malleolus) is incorrect because the AIIS is not typically used as a reference point for leg length measurement.