Which finding during a peripheral vascular assessment is most concerning?

Correct Answer: C

Rationale: The correct answer is C: Absent dorsalis pedis pulse. This finding is most concerning as it indicates a significant impairment in arterial blood flow to the foot, potentially leading to severe complications such as tissue necrosis or limb ischemia. Absence of the dorsalis pedis pulse suggests a severe blockage or narrowing in the arteries supplying the foot, which requires immediate medical attention to prevent further complications. Capillary refill of 2 seconds (choice A) is within the normal range and indicates adequate peripheral circulation. Bilateral pitting edema (choice B) can be a sign of venous insufficiency but is not as urgent as an absent dorsalis pedis pulse. Warm and pink extremities (choice D) indicate good tissue perfusion and are positive findings in a vascular assessment.

Correct Answer: A

Rationale: The most likely diagnosis for the 30-year-old woman with shortness of breath, dry cough, and a history of frequent sinus infections is Sarcoidosis. This is because Sarcoidosis commonly presents with respiratory symptoms such as cough and dyspnea, and can be associated with sinus involvement. Sarcoidosis is more common in younger individuals, like the patient in this case, compared to lung cancer or COPD. Pneumonia typically presents with fever and productive cough, which are not mentioned in the patient's symptoms. Chronic obstructive pulmonary disease (COPD) is more commonly seen in older individuals with a history of smoking, which is not indicated in this case. Therefore, the most likely diagnosis is Sarcoidosis based on the patient's age, symptoms, and medical history.

Correct Answer: A

Rationale: The correct answer is A: Cerebellar ataxia. Difficulty walking on toes is a sign of cerebellar dysfunction, affecting coordination and balance. The cerebellum plays a crucial role in coordinating voluntary movements, including maintaining balance and posture. In cerebellar ataxia, there is a lack of coordination in muscle movements, leading to difficulties in performing fine motor tasks like walking on toes. Peripheral neuropathy (B) primarily affects sensory and motor nerves in the limbs, causing tingling, numbness, and weakness, not specifically difficulty in walking on toes. Parkinson's disease (C) is characterized by tremors, rigidity, and bradykinesia but typically does not present with difficulty walking on toes. Stroke (D) can cause motor deficits but typically does not manifest as isolated difficulty walking on toes.

Correct Answer: C

Rationale: The correct answer is C: Cluster headache. This is because the patient's symptoms of severe one-sided headaches lasting 30 minutes to an hour, associated with eye watering and nasal congestion, are classic features of cluster headaches. These headaches are often described as excruciating and occur in clusters or cycles. Other choices can be ruled out based on the specific characteristics of the headaches described. Migraines typically last longer, tension-type headaches are usually bilateral and milder in intensity, and sinus headaches are often associated with sinus infections which the patient does not present with.

Correct Answer: B

Rationale: The correct answer is B: Document the murmur and report it to the physician. A grade 3/6 murmur is moderate in intensity and may indicate a significant underlying heart condition. By documenting and reporting it to the physician promptly, the nurse ensures timely evaluation and appropriate management. Reassessing the murmur in 30 minutes (choice A) may delay necessary intervention. Performing a complete physical examination to rule out other cardiac abnormalities (choice C) is important but may not be immediately necessary for addressing the murmur. Initiating cardiac monitoring immediately (choice D) is not the priority in this scenario; informing the physician for further evaluation is more crucial.