A patient with longstanding COPD was told by another practitioner that his liver was enlarged and this needed to be assessed. Which of the following would be reasonable to do next?

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Measure the span of the liver. This is the most reasonable next step because an enlarged liver can be indicative of various conditions, including COPD-related complications or comorbidities. Measuring the span of the liver can provide valuable information about its size and potential enlargement, helping to confirm the initial observation and guide further diagnostic investigations or treatment plans. Option A) Percuss the lower border of the liver may not provide as accurate or comprehensive information about the size of the liver compared to actually measuring its span. Percussion alone may not be sufficient to confirm the extent of liver enlargement. Option C) Ordering a hepatitis panel would not be the next immediate step in this case unless there were specific clinical indications or risk factors suggesting hepatitis as a likely cause of liver enlargement. It is important to prioritize investigations based on the patient's presentation and relevant findings. Option D) Obtaining an ultrasound of the liver may be a valuable diagnostic tool, but measuring the liver span is a less invasive and more cost-effective initial step to assess liver enlargement before proceeding to imaging studies. Educationally, this question emphasizes the importance of systematic and logical clinical reasoning in assessing patients with suspected liver abnormalities. It highlights the significance of choosing the most appropriate initial diagnostic steps based on the clinical context, patient history, and physical examination findings. Understanding the rationale behind selecting the correct next step in this scenario is crucial for healthcare providers to enhance their diagnostic skills and improve patient care outcomes.

Correct Answer: B

Rationale: By providing false assurance or reassurance, this courage builder relieves the woman's anxiety and gives the nurse the false sense of having provided comfort. However, for the woman, providing false assurance or reassurance actually closes off communication, trivializes her anxiety, and effectively denies any further talk of it.

Correct Answer: D

Rationale: In this scenario, option D, which is to focus on areas related to the problem and finish later, is the correct approach for the nurse to take when assessing a hospitalized patient with significant shortness of breath. This option is the most appropriate because addressing the immediate concern of shortness of breath is crucial for the patient's well-being. By focusing on areas related to the problem first, the nurse can quickly gather essential information to initiate appropriate interventions to alleviate the patient's distress. Option A, laying the patient flat for accurate cardiac and respiratory assessments, is incorrect in this case because it can worsen the patient's shortness of breath due to increased pressure on the chest and lungs. This action could further compromise the patient's respiratory status. Option B, obtaining a detailed history from a family member, is not the priority when a patient is experiencing significant shortness of breath. While obtaining a thorough history is important, addressing the immediate physiological needs of the patient takes precedence in this situation. Option C, performing a complete physical assessment immediately, is also not the best course of action because it may be overwhelming for the patient and could delay the prompt intervention needed for the shortness of breath. In an educational context, it is essential for healthcare providers to prioritize and manage acute symptoms effectively. By focusing on the problem at hand, nurses can provide timely and appropriate care to address the patient's immediate needs while still maintaining a comprehensive approach to care. This approach ensures that critical issues are addressed promptly, leading to better patient outcomes.

Correct Answer: B

Rationale: The correct answer is B) Prehypertension. Prehypertension is defined as a blood pressure reading that is higher than normal but not high enough to be considered hypertension. In this case, the patient's average blood pressure reading of 126/86 mm Hg falls within the prehypertension range. Option A) Normal blood pressure is incorrect because the patient's average blood pressure reading is higher than what is considered normal (which is typically around 120/80 mm Hg). Option C) Stage 1 hypertension and Option D) Stage 2 hypertension are also incorrect because the patient's blood pressure readings do not fall within the ranges defined for these categories. Stage 1 hypertension is typically defined as readings between 130-139/80-89 mm Hg, and Stage 2 hypertension is readings above 140/90 mm Hg. Educationally, understanding blood pressure categories is crucial for healthcare professionals to accurately assess and manage patients' cardiovascular health. Monitoring blood pressure trends over time helps in identifying potential health risks and guiding appropriate interventions to prevent complications associated with hypertension. It is essential for nurses to interpret and classify blood pressure readings correctly to provide optimal patient care.

Correct Answer: A

Rationale: The correct answer is A) Respirations should be counted for 1 full minute, noticing rate and rhythm. This is the appropriate way to assess a child's respirations, especially when irregularities are suspected. Counting respirations for a full minute provides a more accurate representation of the child's breathing pattern, allowing the nurse to observe any variations in rate, depth, and rhythm. Option B) Child's pulse and respirations should be simultaneously checked for 30 seconds, is incorrect because focusing on both pulse and respirations simultaneously may lead to inaccuracies in counting one or both of these vital signs. It is important to assess respirations independently for a full minute to ensure accuracy. Option C) Child's respirations should be checked for a minimum of 5 minutes to identify any variations in his or her respiratory pattern, is incorrect as it is not practical or necessary to monitor a child's respirations for such an extended period of time during a routine assessment. One minute is generally sufficient to assess respiratory rate and rhythm. Option D) Patient's respirations should be counted for 15 seconds and then multiplied by 4 to obtain the number of respirations per minute, is incorrect because this method may not capture any irregularities or fluctuations in the child's respiratory pattern that could be observed over a full minute. In an educational context, understanding the proper technique for assessing vital signs in pediatric patients is crucial for providing safe and effective nursing care. Teaching students to count respirations for a full minute allows them to develop the skills necessary to accurately assess and monitor a child's breathing pattern, which is essential in detecting any potential respiratory issues or abnormalities. It also emphasizes the importance of thorough assessment techniques in pediatric nursing practice to ensure the well-being of young patients.