For which of the following patients would a comprehensive health history be appropriate?

Correct Answer: C

Rationale: In this scenario, the correct answer is C) A new patient with the chief complaint of 'I am here to establish care'. A comprehensive health history is appropriate for this patient because they are new, and establishing care involves gathering detailed information about their past medical history, family history, lifestyle factors, and any underlying conditions. This information is crucial for creating a baseline understanding of the patient's health status and developing an appropriate care plan. Option A, a new patient with a sprained ankle, would likely require a focused health history related to the injury and its management. Option B, an established patient with an upper respiratory infection, would need a focused assessment on the current illness. Option D, a new patient with a cut hand, would require a focused history on the injury and wound care. Educationally, understanding the importance of differentiating when to conduct a comprehensive health history versus a focused history is crucial for healthcare providers in delivering effective and patient-centered care. It ensures that the right information is gathered to make informed decisions about the patient's health and well-being.

Correct Answer: C

Rationale: The correct answer is option C: "The patient states, 'I have a fever and chills.'" This statement accurately describes the chief complaint. In a healthcare setting, the chief complaint is the patient's own words describing the primary reason for seeking medical attention. It is essential in guiding further assessment and treatment. Option A provides a scenario but does not directly quote the patient's complaint, making it less specific. Option B focuses on associated symptoms rather than the primary complaint. Option D mentions a symptom the patient denies, which is not the same as stating the chief complaint. In an educational context, understanding the concept of chief complaint is crucial for healthcare professionals to prioritize and address the patient's primary concerns effectively. By recognizing and documenting the chief complaint accurately, healthcare providers can better diagnose and treat patients. This skill is fundamental in providing patient-centered care and ensuring positive health outcomes.

Correct Answer: C

Rationale: In a respiratory assessment, when a nurse observes a patient with a prolonged expiration phase, the most likely condition associated with this finding is Chronic Obstructive Pulmonary Disease (COPD). The rationale behind this is that in COPD, which includes conditions such as chronic bronchitis and emphysema, there is an obstruction of airflow in the lungs. This obstruction can lead to difficulties in exhaling air, resulting in a prolonged expiration phase. Patients with COPD often experience air trapping in the lungs due to narrowed airways, leading to this characteristic finding. The other options can be ruled out for the following reasons: A) Asthma typically presents with wheezing and a prolonged expiration phase is not a common feature. B) Pneumonia is characterized by symptoms such as fever, cough with sputum production, and chest pain, rather than a prolonged expiration phase. D) Pulmonary embolism usually presents with sudden onset shortness of breath, chest pain, and sometimes coughing up blood, not necessarily a prolonged expiration phase. Understanding these distinctions is crucial for nurses to accurately assess and identify respiratory conditions in patients. It also highlights the importance of recognizing specific clinical manifestations to provide appropriate interventions and care tailored to the patient's condition.

Correct Answer: C

Rationale: In this scenario, the correct answer is C) Genu recurvatum. Genu recurvatum is a condition where the knees hyperextend beyond a normal range. This can be observed during a musculoskeletal assessment when the knees appear to bend backward excessively. A) Genu valgum refers to knock knees where the knees angle inward, which is not the case in hyperextension. B) Genu varum is a condition where the knees bow outward, again not indicative of hyperextension. D) Osteoarthritis is a degenerative joint disease that can affect the knees but does not specifically present as hyperextension. Understanding musculoskeletal assessments is crucial for nurses to identify various conditions accurately. Recognizing the specific presentation of genu recurvatum can help in determining appropriate interventions and referrals for the patient. It is essential for nurses to be able to differentiate between different musculoskeletal abnormalities to provide comprehensive care.

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Cranial nerve V (trigeminal nerve). The trigeminal nerve is responsible for sensory functions in the face, including detecting light touch. When the nurse asks the patient to close their eyes and report if they can feel light touch on their face, they are assessing the sensory function of the trigeminal nerve. Option B) Cranial nerve VII (facial nerve) is responsible for facial movement and expression, not sensation. Option C) Cranial nerve IX (glossopharyngeal nerve) is involved in taste sensation at the back of the tongue and throat, not facial sensation. Option D) Cranial nerve X (vagus nerve) is responsible for various functions like heart rate and digestion, but not facial sensation. Understanding cranial nerve functions is crucial for healthcare providers to accurately assess patients' neurological status. Testing cranial nerve function helps identify any abnormalities or issues that may require further evaluation or intervention. By knowing which nerve is being tested in specific assessments, nurses and other healthcare professionals can provide comprehensive care and support to their patients.