The nurse is assessing the abdomen of a patient and notes visible peristalsis. What does this finding most likely indicate?

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: 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.

Correct Answer: B

Rationale: The correct answer is B: Administer oxygen as prescribed. When a patient has an increased work of breathing, providing oxygen helps improve oxygenation and reduces the respiratory effort. It is the priority action to address potential hypoxia. Encouraging deep breathing exercises (A) may worsen the situation by increasing respiratory effort. Chest physiotherapy (C) is not indicated as the primary intervention for increased work of breathing. Providing a bronchodilator treatment (D) may be beneficial but addressing oxygenation is the priority.