During a cardiac assessment, the nurse notes a pulse deficit. How is this finding assessed?

Correct Answer: A

Rationale: To assess a pulse deficit, the nurse should first measure the apical pulse (using a stethoscope at the apex of the heart) and the radial pulse (at the wrist) simultaneously for a full minute. This is because the apical pulse represents the heart's contraction and the radial pulse represents the pulse felt at the periphery. The difference between the two rates indicates a pulse deficit, which suggests that not all heartbeats are reaching the periphery. This method allows for a direct comparison between the heart rate and the peripheral pulse rate. The other choices are incorrect because measuring the pulse strength in both radial arteries (B) does not assess for a pulse deficit, auscultating for murmurs (C) is not directly related to assessing a pulse deficit, and palpating carotid and femoral pulses simultaneously (D) does not provide a comparison between the heart rate and peripheral pulse rate.

Correct Answer: C

Rationale: Subjective findings are based on the patient's symptoms or feelings that cannot be directly observed or measured. In this case, choice C - "The patient reports pain in the right upper quadrant" is the correct answer because it represents a subjective finding as it is based on the patient's self-report of pain. Choices A, B, and D are objective findings as they can be directly observed or measured by the healthcare provider. Pitting edema in the legs, tenderness in the right upper quadrant, and a pulse of 90 are all objective findings that can be assessed through physical examination or measurement.

Correct Answer: A

Rationale: The correct answer is A: Tingling in the hands. Neurological symptoms typically involve abnormalities in the nervous system, such as tingling in the hands, which could indicate nerve damage or dysfunction. This symptom is commonly associated with conditions like peripheral neuropathy. Choices B, C, and D are not typically documented under the neurological system. Cough is related to the respiratory system, abdominal pain is related to the gastrointestinal system, and difficulty urinating is related to the genitourinary system. Therefore, the most appropriate choice related to the neurological system among the options provided is A.

Correct Answer: B

Rationale: The correct answer is B: Administer oxygen as prescribed. When a patient has an increased work of breathing, providing oxygen helps improve oxygenation and reduces the respiratory effort. It is the priority action to address potential hypoxia. Encouraging deep breathing exercises (A) may worsen the situation by increasing respiratory effort. Chest physiotherapy (C) is not indicated as the primary intervention for increased work of breathing. Providing a bronchodilator treatment (D) may be beneficial but addressing oxygenation is the priority.

Correct Answer: B

Rationale: The correct answer is B: Perform the confrontation test. This test evaluates the peripheral visual field by comparing the patient's visual field with the examiner's. It specifically assesses cranial nerve II function, as it tests the patient's ability to see objects in their peripheral vision. Asking the patient to follow an object with their eyes (A) primarily tests eye movement controlled by cranial nerves III, IV, and VI. Testing the corneal reflex (C) evaluates cranial nerves V and VII, involved in the sensation and motor function of the cornea. Assessing the patient's ability to smile (D) is related to cranial nerve VII function, responsible for facial muscle control.