During a health history interview, a female patient states that she has noticed a few drops of clear discharge from her right nipple. What should the nurse do next?

Correct Answer: C

Rationale: The use of some medications, such as oral contraceptives, phenothiazines, diuretics, digitalis, steroids, methyldopa, and calcium channel blockers, may cause clear nipple discharge. Bloody or blood-tinged discharge from the nipple, not clear, is significant, especially if a lump is also present. In the pregnant female, colostrum would be a thick, yellowish liquid, and it would be normally expressed after the fourth month of pregnancy.

Correct Answer: B

Rationale: In assessing for an S4 heart sound, the nurse would listen with the bell of the stethoscope at the apex with the patient in the left lateral position (Option B). The S4 heart sound is best heard at the apex, which is the point of maximum impulse (PMI) located at the 5th intercostal space mid-clavicular line. Placing the patient in the left lateral position helps to bring the apex closer to the chest wall, making it easier to auscultate the S4 sound. Option A is incorrect because listening at the base with the bell of the stethoscope is more appropriate for hearing murmurs associated with valvular abnormalities. Option C is incorrect as the aortic area is not where the S4 heart sound is best heard. Option D is incorrect because listening in the pulmonic area with the diaphragm is more suitable for assessing breath sounds, not heart sounds. Educationally, understanding the correct positioning and technique for auscultating specific heart sounds is crucial for accurate assessment and diagnosis. Students and healthcare professionals need to grasp the rationale behind each step of a physical assessment to provide optimal patient care.

Correct Answer: C

Rationale: A cystic structure will often transilluminate well. While a transilluminator head for your battery handle is ideal, it is possible to use an otoscope to transilluminate the scrotum. You should be able to get above the mass on palpation and bowel sounds should not be present. If they are, it should lead you to consider an inguinal hernia. Scrotal edema involves thickened skin which can be measured by gently pinching a section of the scrotum itself.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Auscultate the site for a bruit. Auscultating for a bruit over the femoral pulse can provide crucial information about the presence of a vascular abnormality such as atherosclerosis or stenosis. A bruit indicates turbulent blood flow in the artery, suggesting a potential blockage or narrowing. This finding requires further investigation and possible intervention to prevent complications like thrombosis or embolism. Option A) Document the finding is incorrect because simply documenting the diminished pulse without further assessment could lead to overlooking a significant issue. Option C) Check for calf pain is incorrect because calf pain is associated with peripheral arterial disease and not directly related to the diminished femoral pulse. Option D) Check capillary refill in the toes is incorrect as it assesses peripheral perfusion and not specifically related to the femoral pulse assessment. In an educational context, understanding the significance of assessing pulses and recognizing abnormal findings is crucial for nurses to provide comprehensive care and early intervention for potential vascular issues. This case highlights the importance of thorough assessment skills and critical thinking in nursing practice to ensure timely and appropriate patient care.

Correct Answer: C

Rationale: In the context of a patient presenting with a cough, the correct anatomic region responsible for this symptom is the cardiac region (Option C). This is because conditions affecting the heart, such as heart failure or certain arrhythmias, can lead to a cough due to fluid buildup in the lungs or stimulation of the cough reflex by an enlarged heart pressing on the airways. Option A, Ophthalmologic, is incorrect as it pertains to the eyes and vision, which are not directly related to causing a cough. Option B, Auditory, refers to the ears and hearing, which do not have a direct connection to coughing. Option D, Endocrine, involves glands like the thyroid or pancreas, which also do not typically manifest in cough symptoms. In an educational context, understanding the relationship between different anatomical regions and associated symptoms is crucial for healthcare professionals. Recognizing the potential causes of cough based on anatomical knowledge aids in accurate assessment, diagnosis, and treatment planning for patients presenting with respiratory symptoms. It underscores the importance of a comprehensive health assessment encompassing various body systems to provide optimal patient care.