While counting the apical pulse on a 16-year-old patient, the nurse notices an irregular rhythm. His rate speeds up on inspiration and slows on expiration. What would be the nurse's response?

Correct Answer: C

Rationale: The correct answer is C: No further response is needed because sinus arrhythmia can occur normally. Sinus arrhythmia is a common finding in young individuals, characterized by a variation in heart rate with respiration. In this case, the irregular rhythm of the apical pulse with speeding up on inspiration and slowing on expiration is consistent with sinus arrhythmia. It is a benign condition and does not require further intervention. Options A and D are incorrect as they are unnecessary and may cause unnecessary worry for the patient. Option B is also unnecessary at this point as the irregular rhythm is likely due to sinus arrhythmia and does not require immediate ECG confirmation.

Correct Answer: B

Rationale: The correct answer is B: Presence of palpable lymph nodes. In children, lymph nodes are more superficial and easily palpable due to their higher metabolic rate and active immune system. This is a normal finding in healthy children. Excessive swelling of lymph nodes (A) would indicate an abnormal response to infection. The absence of palpable nodes (C) is not expected as even in young children, lymph nodes are palpable. Having fewer and smaller lymph nodes (D) is not typical in healthy children and would be concerning for an underlying issue.

Correct Answer: C

Rationale: The correct answer is C: Swishing, whooshing sound. This sound indicates venous flow in Doppler ultrasonic stethoscope. Venous flow produces a continuous, swishing sound due to the irregularity of blood flow in veins. Option A, a low humming sound, does not accurately represent venous flow. Option B, a regular 'lub, dub' pattern, is typical of normal heart sounds. Option D, a steady, even, flowing sound, does not reflect the nature of venous flow, which is more turbulent and irregular.

Correct Answer: C

Rationale: The correct answer is C: Rapid and deep breathing. In diabetic ketoacidosis, the body compensates for metabolic acidosis by increasing the respiratory rate (rapid) and depth (deep) in an effort to blow off excess carbon dioxide and decrease blood acidity. This is known as Kussmaul breathing. Option A is incorrect because normal breathing would not be expected in a state of metabolic acidosis. Option B is incorrect as rapid and shallow breathing is not typically seen in diabetic ketoacidosis. Option D is incorrect as slow breathing is not a characteristic of compensatory mechanisms in diabetic ketoacidosis.

Correct Answer: D

Rationale: The correct answer is D because in an emergency situation with a patient who has severe injuries, the top priority is to collect critical information as you begin lifesaving measures. This includes obtaining information such as the patient's name, age, allergies, current medications, and any known medical conditions. This information is crucial for providing appropriate and timely treatment to the patient. Options A, B, and C are incorrect because in a life-threatening emergency, collecting the complete health history, full physical examination, or detailed medical history should not delay immediate life-saving interventions. Prioritizing critical information gathering ensures that necessary actions are taken promptly to stabilize the patient's condition.