The nurse is preparing to assess a patient's deep tendon reflexes. Which tool is most appropriate for this assessment?

Correct Answer: B

Rationale: The correct answer is B: Reflex hammer. This tool is specifically designed to assess deep tendon reflexes by eliciting a quick stretch reflex response. The pointed end of the reflex hammer is used to strike the tendon, causing a quick tap that triggers the reflex. The other choices are incorrect: A tuning fork is used for testing auditory sensations, a penlight is used for assessing pupillary responses and examining the eyes, and an otoscope is used for visualizing the ear canal and eardrum. Therefore, the reflex hammer is the most appropriate tool for assessing deep tendon reflexes due to its specific design and function.

Correct Answer: B

Rationale: The primary purpose of palpating the costovertebral angle during an abdominal assessment is to evaluate kidney tenderness. This area is specifically associated with the kidneys, so tenderness in this region could indicate renal issues. Palpating for rebound tenderness (choice A) is typically done in the abdominal quadrants, not the costovertebral angle. Checking for abdominal aortic pulsation (choice C) is usually done in the epigastric area, not the costovertebral angle. Assessing liver size (choice D) is typically done by percussion and palpation in the right upper quadrant, not at the costovertebral angle.

Correct Answer: B

Rationale: The correct answer is B: Consensual light reflex. When both pupils constrict in response to light directed into one eye, it indicates a consensual light reflex. This response occurs due to the connection between the optic nerves, causing both pupils to constrict simultaneously. This reflex is an involuntary response and ensures that both eyes react to changes in light intensity equally. Choice A (Direct light reflex) refers to the constriction of the pupil in response to light directly shining into that same eye, not both eyes simultaneously. Choice C (Accommodation) involves the adjustment of the lens to focus on near objects and is not related to pupillary response. Choice D (Convergence) refers to the inward movement of both eyes when focusing on a nearby object and is not related to pupillary response to light.

Correct Answer: A

Rationale: The correct answer is A: Cranial nerve II (optic nerve). During confrontation testing, the nurse checks each eye's peripheral vision to assess cranial nerve II function. This nerve is responsible for vision. Choices B, C, and D are incorrect as cranial nerve III controls eye movement, cranial nerve IV controls eye movement of the superior oblique muscle, and cranial nerve VI controls eye movement of the lateral rectus muscle, respectively.

Correct Answer: D

Rationale: The correct answer is D: Review of systems. In a health history, the review of systems involves asking about specific symptoms related to different body systems. In this case, the information provided relates to symptoms associated with the cardiovascular system. The patient denying chest pain, palpitations, orthopnea, and paroxysmal nocturnal dyspnea indicates a review of symptoms related to the cardiovascular system. Choices A, B, and C are incorrect because the information provided does not pertain to the patient's primary reason for seeking care (chief complaint), the current symptoms and duration (present illness), or personal and social history.