Which of the following findings during a cardiovascular assessment would require immediate intervention?

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: 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.

Correct Answer: B

Rationale: The correct answer is B: Consensual light reflex. When both pupils constrict in response to light directed into one eye, it indicates a consensual light reflex. This response occurs due to the connection between the optic nerves, causing both pupils to constrict simultaneously. This reflex is an involuntary response and ensures that both eyes react to changes in light intensity equally. Choice A (Direct light reflex) refers to the constriction of the pupil in response to light directly shining into that same eye, not both eyes simultaneously. Choice C (Accommodation) involves the adjustment of the lens to focus on near objects and is not related to pupillary response. Choice D (Convergence) refers to the inward movement of both eyes when focusing on a nearby object and is not related to pupillary response to light.

Correct Answer: A

Rationale: The correct answer is A: Cranial nerve II (optic nerve). During confrontation testing, the nurse checks each eye's peripheral vision to assess cranial nerve II function. This nerve is responsible for vision. Choices B, C, and D are incorrect as cranial nerve III controls eye movement, cranial nerve IV controls eye movement of the superior oblique muscle, and cranial nerve VI controls eye movement of the lateral rectus muscle, respectively.