The nurse is assessing a patient's capillary refill time. What is the normal finding for this assessment?

Correct Answer: B

Rationale: The correct answer is B: Less than 2 seconds. Capillary refill time measures the time it takes for blood to return to the capillaries after pressure is applied and released. A normal finding is less than 2 seconds, indicating adequate peripheral perfusion. Choices A, C, and D are incorrect as they exceed the normal capillary refill time, which could suggest inadequate circulation and potential perfusion issues. Choice A (<1 second) may indicate hypervolemia or vasodilation, while choices C (>3 seconds) and D (>4 seconds) may indicate hypovolemia or vasoconstriction, respectively. Hence, the correct answer is less than 2 seconds, as it indicates normal capillary refill time and adequate blood flow.

Correct Answer: A

Rationale: The correct answer is A: Pericardial friction rub, as it is a high-pitched, scratchy sound heard during both systole and diastole, indicating inflammation of the pericardium. This sound is produced by the rubbing of inflamed pericardial layers during the cardiac cycle. B: Aortic stenosis produces a systolic murmur. C: Mitral valve regurgitation produces a holosystolic murmur. D: Heart murmur is a generic term and does not specifically describe the high-pitched, scratchy sound heard during both systole and diastole.

Correct Answer: D

Rationale: The correct answer is D, Intracranial hypertension. This condition is characterized by increased pressure within the skull, leading to symptoms such as morning headaches, nausea, vomiting, blurred vision, and papilledema. The patient's presentation of severe morning headaches with associated symptoms and papilledema is classic for intracranial hypertension. Migraine (A) typically presents with pulsating headaches without neurological signs. Cluster headache (B) is characterized by severe unilateral headaches with autonomic features but not typically associated with papilledema. Tension-type headache (C) is usually bilateral, mild to moderate in intensity, and not associated with papilledema. In summary, the patient's symptoms and signs are most consistent with intracranial hypertension due to the presence of morning headaches, nausea, vomiting, blurred vision, and papilledema.

Correct Answer: C

Rationale: The most likely diagnosis for the 40-year-old man with fatigue, weight loss, chronic cough, and a mass in the left upper lobe on chest X-ray is lung cancer (Choice C). 1. Symptoms: Fatigue, weight loss, night sweats are common in lung cancer due to systemic effects. 2. History: Smoking and chronic cough are major risk factors for lung cancer. 3. Imaging: Presence of a mass in the left upper lobe on chest X-ray is highly suggestive of lung cancer. 4. Exclusion: Pneumonia (Choice A) typically presents with fever and productive cough, not weight loss. Tuberculosis (Choice B) may show upper lobe involvement but is less common in non-endemic areas without known exposure. Chronic obstructive pulmonary disease (Choice D) does not typically present with weight loss or night sweats.

Correct Answer: B

Rationale: The correct answer is B: Hypertensive emergency. The patient's symptoms of persistent headache, blurred vision, and high blood pressure indicate a hypertensive emergency, a severe increase in blood pressure requiring immediate medical attention to prevent organ damage. Primary hypertension (A) is chronic high blood pressure without acute symptoms. Cluster headache (C) is characterized by severe, unilateral head pain with associated symptoms, not necessarily elevated blood pressure. Migraine (D) is a recurrent headache disorder with specific features, not typically associated with such high blood pressure levels.