The nurse is performing a physical assessment on a newly admitted patient. An example of objective information obtained during the physical assessment includes the:

Correct Answer: D

Rationale: The correct answer is D because a 2.5 cm scar on the right lower forearm is an observable and measurable physical finding. Objective information in a physical assessment is data that can be directly observed or measured by the healthcare provider. Scars are physical characteristics that can be visually confirmed, making them objective. Choices A, B, and C are subjective information as they rely on the patient's report or history, which may be influenced by memory, perception, or interpretation. Therefore, they are not considered objective data.

Correct Answer: B

Rationale: The correct diagnosis for this patient is external otitis (choice B). The key findings that support this diagnosis include pain on manipulation of the ear, especially the tragus, narrowed and erythematous ear canal, drainage, and white debris in the canal. These are classic signs of external otitis, also known as swimmer's ear, which is an infection of the ear canal. Otitis media (choice A) typically presents with middle ear inflammation and fluid accumulation, but this patient's symptoms are more consistent with an external ear infection. Perforation of the tympanum (choice C) would present with different symptoms, such as hearing loss, ear discharge, and possible pain, but the examination findings described do not suggest a perforation. Cholesteatoma (choice D) is a benign growth in the middle ear and does not typically present with the external ear canal findings described in the patient.

Correct Answer: A

Rationale: The correct answer is A: Obtain an abdominal ultrasound. A pulsatile mass in an elderly smoker raises concern for an abdominal aortic aneurysm (AAA). An abdominal ultrasound is the best initial diagnostic test to confirm the presence of an AAA. If left untreated, AAA can lead to life-threatening complications such as rupture. Choice B (Reassess in 6 months) and C (Reassess in 3 months) are incorrect as immediate investigation is necessary due to the potential seriousness of an AAA. Choice D (Refer to a vascular surgeon) is premature without confirming the presence of an AAA through imaging. An ultrasound is needed first to guide further management.

Correct Answer: A

Rationale: The correct answer is A: Palpation. Palpation involves using the hands to feel for abnormalities such as crepitus (crackling or grating sensation), swelling, and pulsations. It allows the nurse to assess textures, temperatures, and tenderness. Inspection (B) involves visual examination, which may not detect subtle abnormalities like crepitus. Percussion (C) is tapping on the body to assess underlying structures and is not used for detecting crepitus, swelling, or pulsations. Auscultation (D) involves listening with a stethoscope and is used for assessing sounds like heartbeats or breath sounds, not the physical characteristics mentioned in the question.

Correct Answer: C

Rationale: Step-by-step rationale: 1. Increased ICP can lead to cerebral edema and worsen neurological outcomes. 2. Promoting carbon dioxide elimination helps reduce cerebral blood flow and intracranial pressure. 3. Hyperventilation decreases PaCO2, causing vasoconstriction and reducing ICP. 4. Preventing respiratory alkalosis (A) and lowering arterial pH (B) are incorrect as they can worsen cerebral vasoconstriction. 5. Maintaining PaO2 above 80 mm Hg (D) is important but not the primary goal in managing increased ICP.