During a respiratory assessment, the nurse notes that the patient has increased tactile fremitus over the left lower lung field. What does this finding suggest?

Correct Answer: A

Rationale: In a respiratory assessment, increased tactile fremitus over the left lower lung field suggests pneumonia. Tactile fremitus is the vibration felt on the chest wall when a patient speaks; it is increased when lung density is higher, as in pneumonia. Option A is correct because pneumonia causes consolidation in the lung tissue, increasing density and leading to increased tactile fremitus. Option B, pleural effusion, is incorrect because it involves fluid accumulation in the pleural space, which typically decreases tactile fremitus. Option C, pulmonary embolism, is incorrect as it involves a blockage in the pulmonary artery, not affecting tactile fremitus. Option D, asthma, is incorrect because asthma is characterized by airway constriction and inflammation, not changes in lung density affecting tactile fremitus. Educationally, understanding these findings is crucial for nurses to make accurate assessments and provide appropriate care. Recognizing the significance of increased tactile fremitus in pneumonia can prompt timely interventions and prevent complications.

Correct Answer: A

Rationale: The correct answer is A) Cranial nerve I (olfactory nerve) because the olfactory nerve is responsible for the sense of smell. When the nurse asks the patient to identify familiar smells with their eyes closed, they are testing the function of the olfactory nerve. This test helps assess the patient's ability to detect and differentiate various odors, which is crucial for overall health assessment. Option B) Cranial nerve II (optic nerve) is responsible for vision, not smell. Testing vision would involve tasks such as reading an eye chart or identifying objects at different distances. Option C) Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupil constriction, not the sense of smell. Testing this nerve would involve assessing pupillary response and eye movements. Option D) Cranial nerve V (trigeminal nerve) is responsible for sensation in the face and motor functions such as chewing. Testing this nerve would involve assessing facial sensation and the ability to clench the jaw. Understanding the functions of each cranial nerve is essential for nurses and healthcare providers when performing a comprehensive health assessment. By correctly identifying the cranial nerve being tested in each clinical scenario, healthcare professionals can accurately evaluate the patient's neurological function and provide appropriate care.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cholecystitis. When a nurse elicits a positive Murphy's sign during an abdominal assessment, it indicates inflammation of the gallbladder, which is a classic sign of cholecystitis. Murphy's sign is elicited by asking the patient to take a deep breath while the nurse palpates the right upper quadrant of the abdomen just below the rib cage. If the patient stops breathing due to pain during inspiration, it suggests inflammation of the gallbladder pressing against the inflamed liver, indicating cholecystitis. Option B) Pancreatitis is incorrect because Murphy's sign is not typically associated with pancreatitis. Pancreatitis is usually characterized by epigastric pain radiating to the back, nausea, and vomiting. Option C) Appendicitis is incorrect because Murphy's sign is specific to cholecystitis and is not typically associated with inflammation of the appendix. Appendicitis usually presents with right lower quadrant pain, fever, and rebound tenderness at McBurney's point. Option D) Gastritis is incorrect because Murphy's sign is not associated with gastritis. Gastritis is inflammation of the stomach lining and presents with symptoms like epigastric pain, nausea, and bloating. Educationally, understanding the significance of Murphy's sign in diagnosing cholecystitis is crucial for nurses conducting abdominal assessments. Recognizing the correlation between this physical exam finding and the associated condition helps in prompt identification and appropriate management of the patient's health condition.

Correct Answer: D

Rationale: Pain, is correct as its widely recognized as the fifth vital sign in modern healthcare, alongside temperature, pulse, respiration, and blood pressure. Pain assessment (often via a 0-10 scale) helps evaluate patient comfort and guide treatment, especially post-surgery or in chronic conditions. Height and weight, are metrics, not vital signs. Respiration, is a core vital sign (not fifth). Body mass index, derived from height and weight, isnt directly measured as a vital sign. Since the 1990s, pains inclusion reflects its impact on health status, making D the correct answer per nursing standards emphasizing holistic care.

Correct Answer: B

Rationale: Dyspnea (shortness of breath) requires improving lung expansion. Elevating the head of the bed allows abdominal organs to shift downward, giving the diaphragm more room to move, easing breathing. Removing pillows might flatten the patient, worsening lung expansion. Elevating the foot could increase abdominal pressure on the diaphragm, exacerbating dyspnea. Taking blood pressure is secondary to addressing the immediate respiratory need. Choice B is the priority as it directly improves oxygenation, a critical nursing intervention rooted in anatomical and physiological principles for respiratory distress management.