The nurse is examining a patient who has possible cardiac enlargement. Which statement about percussion of the heart is true?

Correct Answer: C

Rationale: Studies show that percussed cardiac borders do not correlate well with the true cardiac border. Percussion is of limited usefulness with the female breast tissue, in a person who is obese, or in a person with a muscular chest wall. Chest x-ray images or echocardiographic examinations are significantly more accurate in detecting heart enlargement.

Correct Answer: D

Rationale: In this scenario, the correct answer is D) Examine the patient's lower arm and hand, and check for the presence of infection or lesions. The presence of an enlarged right epitrochlear lymph node indicates a local inflammatory process or infection in the hand, lower arm, or fingers on the same side. By examining the lower arm and hand, the nurse can assess for signs of infection, lesions, or any other abnormalities that could be causing the lymph node enlargement. Option A is incorrect because assessing the abdomen for tenderness is not directly related to the finding of an enlarged epitrochlear lymph node. Option B is incorrect as assessing the cervical lymph nodes, while important in general assessment, is not the priority when a specific lymph node enlargement is noted. Option C is incorrect as asking about recent ear infections or sore throats is not likely to provide relevant information related to the localized finding of an enlarged epitrochlear lymph node. Educationally, understanding the significance of lymph node enlargement in specific locations and the importance of localizing the assessment to the affected area can help nurses make accurate clinical judgments and provide appropriate care to patients. It reinforces the importance of thorough physical assessment and the relevance of connecting assessment findings to potential underlying causes.

Correct Answer: D

Rationale: The correct answer is D) An ABI of 0.9 to 0.7 indicates the presence of peripheral vascular disease and mild claudication. This statement is accurate because a normal ABI ranges from 1.0 to 1.4, and a lower ABI suggests the presence of peripheral arterial disease. An ABI between 0.91 and 0.7 is considered borderline, indicating mild to moderate peripheral vascular disease and potential claudication. Option A is incorrect because normal ABI indices range from 1.0 to 1.4, not 0.5 to 1.0. Option B is incorrect as normal ankle pressure is expected to be higher than brachial pressure due to the hydrostatic pressure gradient in the lower extremities. Option C is incorrect because while ABI is a valuable tool in assessing peripheral vascular disease, it is not exclusive to individuals with diabetes but is applicable to a broader population. In an educational context, understanding ABI is crucial for nurses in assessing peripheral vascular disease, especially in patients with conditions like diabetes or hypertension. Correctly interpreting ABI results can aid in early detection, intervention, and prevention of complications related to vascular diseases, emphasizing the importance of accurate assessment and interpretation of vital signs in clinical practice.

Correct Answer: C

Rationale: In the context of vital signs and pain assessment, the correct answer is C) Cough. The reason is that a cough is not typically considered a vital sign or directly related to the general survey or initial assessment of a patient's overall health status. Changes in weight (option A) are important to assess as they can indicate underlying health conditions such as fluid retention or nutritional issues. Fatigue and weakness (option B) are common symptoms that can point to various health issues, including anemia or chronic illnesses. Fever and chills (option D) are crucial symptoms to assess as they can indicate infection or systemic inflammation. Educationally, understanding the significance of each symptom in the context of vital signs and general survey helps healthcare professionals prioritize and assess patients effectively. By excluding symptoms like cough from the vital signs assessment, providers can focus on more critical indicators of a patient's health status. This knowledge aids in comprehensive patient evaluations and timely interventions based on the most relevant information gathered during assessments.

Correct Answer: C

Rationale: In the context of a patient recently placed on antihypertensive medication, the appropriate type of data collection would be a Follow-up database. This choice is correct because the patient's situation calls for monitoring and assessing the response to the new medication over time to evaluate its effectiveness and potential side effects. A Complete database would involve gathering a comprehensive patient history, physical examination, and laboratory tests, which are not necessary in this scenario as the focus is on the specific issue of the new antihypertensive medication. A Focused or problem-centered database would be too limited since it may not capture all the relevant information needed to track the patient's response to the medication adequately. An Emergency database would be inappropriate as this situation does not present an acute or life-threatening condition requiring immediate assessment and intervention. From an educational perspective, understanding the appropriate use of different types of data collection methods is crucial for healthcare providers to effectively assess and manage patient care. Teaching students to match the level of data collection to the clinical situation helps develop their critical thinking and decision-making skills in providing optimal patient care. This rationale underscores the importance of contextually appropriate data collection in healthcare practice.