When performing a peripheral vascular assessment on a patient, the nurse is unable to palpate the ulnar pulses. The patient's skin is warm and capillary refill time is normal. Next, the nurse should:

Correct Answer: C

Rationale: The correct answer is C because the inability to palpate ulnar pulses in a patient with warm skin and normal capillary refill time is considered a normal variation. Ulnar pulses may be less prominent and harder to palpate compared to other pulses. Proceeding with the peripheral vascular evaluation is appropriate as this finding alone does not indicate any abnormalities or conditions that require immediate intervention. Checking for claudication (Choice A) is not necessary as the absence of ulnar pulses does not correlate with claudication. Referring the individual for further evaluation (Choice B) is premature and not warranted based on the information given. Asking about unusual cramping or tingling in the arm (Choice D) is not necessary at this point as the absence of ulnar pulses in this context is not indicative of any specific symptoms.

Correct Answer: D

Rationale: The correct answer is D: To screen for depression. Susanne's symptoms of headaches, muscle aches, and fatigue for an extended period may indicate underlying depression. Screening for depression is important as it is a common cause of somatic symptoms. It is crucial to address mental health concerns that could be contributing to her physical symptoms. Referral to a neurologist (Choice A) or rheumatologist (Choice B) may not be necessary if there are no specific findings to suggest neurological or rheumatologic conditions. Telling the patient you can't find anything (Choice C) without exploring all possibilities is not appropriate. Screening for depression is the most appropriate next step to consider in this case.

Correct Answer: C

Rationale: The correct answer is C: Third-level. Unfamiliarity with heart-healthy dietary guidelines is a third-level priority problem because it is not immediately life-threatening or critical to address in the emergent setting. First-level priority problems are those directly impacting the patient's ABCs (airway, breathing, circulation) or immediate safety. Second-level priority problems are important but do not require immediate intervention to prevent harm. In this case, addressing the chest pain, palpitations, and the patient's appearance of being pale and diaphoretic are first- and second-level priorities as they may indicate a more urgent medical condition that needs immediate attention to ensure the patient's safety and stabilization.

Correct Answer: C

Rationale: The normal range of motion for plantar flexion of the ankle is approximately 50 degrees. This range allows for actions like pointing the toes downward. A: 20 degrees is too limited for normal function. B: 30 degrees is also insufficient for full plantar flexion. D: 90 degrees would be excessive and beyond the normal range of motion for plantar flexion. Therefore, C is the correct answer.

Correct Answer: B

Rationale: The correct answer is B: 60°. Scapulothoracic motion contributes to shoulder abduction by allowing the scapula to upwardly rotate and tilt posteriorly. Since shoulder abduction involves 180°, scapulothoracic motion accounts for half of this motion, which is 90°. Therefore, the correct answer is 60°, as it represents the scapulothoracic motion involved in shoulder abduction. Choices A, C, and D are incorrect because they do not accurately reflect the scapulothoracic motion required for shoulder abduction based on the given information.