The nurse is assessing a patient's cranial nerves. How is cranial nerve II (optic nerve) tested?

Correct Answer: A

Rationale: Step-by-step rationale for why option A is correct: 1. Optic nerve (CN II) is responsible for vision. 2. Testing visual acuity assesses the sharpness of vision. 3. Testing visual fields evaluates peripheral vision. 4. Both tests specifically assess the function of the optic nerve. 5. Assessing pupil response to light (B) tests CN III, CN IV, and CN VI. Eye movements (C) test CN III, IV, and VI. Testing hearing ability (D) involves CN VIII, the vestibulocochlear nerve.

Correct Answer: B

Rationale: Visible peristalsis indicates increased activity of the intestines in attempting to move contents along. This is commonly seen in intestinal obstruction, where the intestines are trying to push against the blockage. This finding is not associated with normal digestion, dehydration, or abdominal distension, making option B the correct answer.

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.