During a respiratory assessment, the nurse observes that the patient's chest moves asymmetrically during inspiration. What is the most likely cause?

Correct Answer: A

Rationale: The correct answer is A: Pneumothorax. During a pneumothorax, air enters the pleural space, causing lung collapse and leading to asymmetric chest movement during inspiration. This occurs because the affected lung cannot fully expand. Other choices are incorrect because pleural effusion and asthma exacerbation usually do not cause asymmetric chest movement, and COPD typically results in symmetric chest movement due to chronic air trapping.

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: B

Rationale: The correct answer is B: Present illness. The present illness section of a health history includes detailed information about the current health problem, such as the duration, characteristics, severity, associated symptoms, and location of the symptoms. In this case, the information provided about the patient's abdominal pain, including its duration, intensity, pattern, associated symptoms, and location, falls under the present illness category. This information is essential for healthcare providers to understand the current health issue and make an accurate diagnosis and treatment plan. Choice A (Chief complaint) typically refers to the main reason for the patient seeking medical attention, which is usually a concise statement in the patient's own words. The information provided is more detailed than a typical chief complaint. Choice C (Personal and social history) includes information about the patient's lifestyle, habits, social support, and past medical history. The information provided is focused on the current health issue rather than personal or social background. Choice D (Review of systems) involves a systematic inquiry

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.