When performing an assessment of a 65-year-old man with a history of hypertension and coronary artery disease, the nurse notices bilateral pitting edema in the lower legs. The skin is puffy and tight but of normal colour. There is no increased redness or tenderness, and the peripheral pulses are equal and strong. In this situation, which of the following is the most likely cause of the edema?

Correct Answer: A

Rationale: The correct answer is A: Heart failure. In this case, the most likely cause of the bilateral pitting edema in the lower legs is heart failure. The pitting edema along with the history of hypertension and coronary artery disease suggests fluid overload due to the heart's inability to pump effectively. The normal skin color, absence of redness or tenderness, and strong peripheral pulses indicate that the edema is not caused by venous thrombosis, local inflammation, or blockage of lymphatic drainage. In heart failure, fluid can accumulate in the lower extremities due to the heart's reduced ability to pump blood efficiently, leading to increased pressure in the veins and subsequent fluid leakage into the surrounding tissues.

Correct Answer: B

Rationale: The bright cherry-red coloring in a semiconscious woman found on the floor in her kitchen indicates carbon monoxide poisoning. Carbon monoxide binds to hemoglobin with a higher affinity than oxygen, leading to tissue hypoxia and the characteristic cherry-red coloration. Polycythemia would result in a purplish-red color, carotenemia in a yellow-orange hue, and uremia in a pale or yellowish complexion. Therefore, the correct answer is B, as it aligns with the clinical presentation and pathophysiology of carbon monoxide poisoning.

Correct Answer: C

Rationale: Step-by-step rationale for why choice C (CN VII) is correct: 1. Palpebral fissures are controlled by muscles innervated by CN VII (facial nerve). 2. Damage to CN VII can result in facial asymmetry, affecting palpebral fissures. 3. CN III (choice A) controls eye movement, not palpebral fissures. 4. CN V (choice B) controls facial sensation, not palpebral fissures. 5. CN VIII (choice D) controls hearing and balance, not palpebral fissures. Summary: Choice C is correct as damage to CN VII affects palpebral fissures due to facial muscle innervation. Choices A, B, and D are incorrect as they do not control the muscles responsible for palpebral fissures.

Correct Answer: A

Rationale: The correct answer is A: sternomastoid and trapezius. CN XI, also known as the spinal accessory nerve, innervates the sternomastoid and trapezius muscles. The sternomastoid muscle is responsible for neck rotation and flexion, while the trapezius muscle is responsible for shoulder movement and stability. The other choices are incorrect because the omohyoid and sternomandibular muscles are not innervated by CN XI. The spinal accessory nerve does not innervate the omohyoid muscle, and the sternomandibular muscle is not a recognized muscle in the neck. Therefore, choices B, C, and D are incorrect.

Correct Answer: C

Rationale: The correct answer is C because lymph nodes are accessible for examination in the head and neck, arms, breasts, and axillae. Lymph nodes are present in these areas where they can be easily palpated and assessed for any signs of inflammation or abnormalities. The other choices are incorrect because they do not include all the areas where lymph nodes are accessible for examination. Choice A does not include the axillae, which is a crucial area for examining lymph nodes in the arms. Choice B does not include the axillae and breasts. Choice D does not include the breasts, which are important areas for lymph node examination in cases of breast cancer or other breast-related conditions.