The nurse is teaching a class on basic assessment skills. Which of these statements is true regarding the stethoscope and its use?

Correct Answer: B

Rationale: The correct answer is B because the statement accurately describes the function of a stethoscope. A stethoscope doesn't magnify sound but rather blocks out extraneous room noise to allow for clear auscultation. This is essential for accurate assessment. Choice A is incorrect as the slope of the earpieces should point towards the nose, not the occiput. Choice C is incorrect because fit and quality are crucial for accurate auscultation, not just the ability to magnify sound. Choice D is incorrect as there isn't an ideal tubing length specified for all stethoscopes, and the focus should be on optimal sound transmission rather than dampening sound.

Correct Answer: C

Rationale: The correct answer is C: Crackles in the lungs. Left-sided heart failure typically results in fluid buildup in the lungs, leading to crackles upon auscultation. This occurs due to the impaired ability of the left side of the heart to adequately pump blood, causing fluid to leak into the lungs. Peripheral edema (A) is more indicative of right-sided heart failure, where blood backs up in the systemic circulation. Jugular vein distension (B) is a sign of increased central venous pressure, often seen in right-sided heart failure. Ascites (D) is the accumulation of fluid in the abdominal cavity and is more commonly associated with liver or kidney disease rather than heart failure.

Correct Answer: B

Rationale: The correct answer is B: Transfer to radiology for a CT scan. This is the first collaborative intervention to implement because the patient's history of falling down the stairs a month ago with subsequent absence of visible injuries raises concern for possible head trauma. The acute lethargy, confusion, and incontinence could be indicative of a traumatic brain injury or intracranial bleeding. A CT scan is crucial to assess for any structural brain abnormalities that may require immediate intervention. Choice A: Placing on the hospital alcohol withdrawal protocol is not the first priority as the patient's symptoms are more suggestive of a potential head injury rather than alcohol withdrawal. Choice C: Inserting a retention catheter to straight drainage may be necessary for managing incontinence, but it does not address the primary concern of assessing for potential head trauma. Choice D: Giving phenytoin (Dilantin) 100 mg PO is not appropriate as the patient's symptoms are not necessarily indicative of seizures and administering ant

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: A

Rationale: The correct answer is A: Pneumothorax. During a pneumothorax, air enters the pleural space, causing lung collapse and leading to asymmetric chest movement during inspiration. This occurs because the affected lung cannot fully expand. Other choices are incorrect because pleural effusion and asthma exacerbation usually do not cause asymmetric chest movement, and COPD typically results in symmetric chest movement due to chronic air trapping.