The nurse will use which technique of assessment to determine the presence of crepitus, swelling, and pulsations?

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: D

Rationale: The correct answer is D because a new onset of chest pain during a cardiovascular assessment could indicate a serious cardiac issue like a heart attack requiring immediate intervention. Chest pain can be a symptom of myocardial infarction, which is a medical emergency. Choices A, B, and C are not immediate concerns. A capillary refill of 3 seconds is within normal limits (2 seconds or less is normal). Blood pressure of 130/80 mmHg is within the normal range, and a heart rate of 110 beats per minute may be elevated but not necessarily an immediate concern without additional context.

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: C

Rationale: The primary purpose of using the Snellen chart during a physical examination is to measure visual acuity, which refers to the sharpness of vision. The chart consists of letters or symbols of varying sizes that the individual is asked to read from a specific distance. By determining the smallest line of text that can be read accurately, the healthcare provider can assess the clarity of the individual's vision. Peripheral vision, depth perception, and color vision are not evaluated using the Snellen chart, making choices A, B, and D incorrect.

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.