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The nurse is examining a patient who tells the nurse, 'I sure sweat a lot, especially on my face and feet but it doesn't have an odor.' The nurse knows that this condition could be related to:
- A. Eccrine glands.
- B. Apocrine glands.
- C. Disorder of the stratum corneum.
- D. Disorder of the stratum germinativum.
Correct Answer: A
Rationale: The correct answer is A: Eccrine glands. Eccrine glands are responsible for producing sweat that is mostly composed of water and salts. Excessive sweating on the face and feet without odor is characteristic of eccrine gland activity. Eccrine glands are distributed throughout the body and help regulate body temperature through sweat production. Apocrine glands, choice B, produce a thicker sweat that can lead to body odor. Choices C and D are related to the skin's outer layers and not directly associated with sweating.
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The nurse is performing a respiratory assessment and notes that the patient has crackles in the lower lung fields. What is the most likely cause of this finding?
- A. Pleural effusion.
- B. Pneumonia.
- C. Pulmonary edema.
- D. Chronic obstructive pulmonary disease (COPD).
Correct Answer: C
Rationale: The correct answer is C: Pulmonary edema. Crackles in the lower lung fields are indicative of fluid accumulation in the alveoli, which is characteristic of pulmonary edema. This condition is commonly seen in heart failure when the heart is unable to effectively pump blood, leading to fluid backup in the lungs. Pleural effusion (A) is the accumulation of fluid in the pleural space, not in the alveoli. Pneumonia (B) typically presents with other symptoms like fever and productive cough. COPD (D) is characterized by airflow limitation and is not directly associated with crackles due to fluid accumulation.
Which of the following is the medically acute inpatient cardiac rehabilitation phase?
- A. Phase 1
- B. Phase 2
- C. Phase 3
- D. Phase 4
Correct Answer: A
Rationale: The correct answer is A: Phase 1. This phase is the medically acute inpatient cardiac rehabilitation phase focused on initial evaluation, stabilization, and education post-cardiac event. Phase 2 involves early outpatient exercise and education, Phase 3 is the maintenance phase, and Phase 4 is long-term independent exercise. Phase 1 is crucial for monitoring and managing acute cardiac issues, making it the correct choice.
The nurse is preparing to perform a physical assessment. Which statement is true about the physical assessment? The inspection phase:
- A. Usually yields little information.
- B. Takes time and reveals a surprising amount of information.
- C. May be somewhat uncomfortable for the expert practitioner.
- D. Requires a quick glance at the patient's body systems before proceeding with palpation.
Correct Answer: B
Rationale: The correct answer is B: Takes time and reveals a surprising amount of information. During the inspection phase of a physical assessment, the nurse carefully observes the patient's appearance, behavior, and movements. This phase is crucial as it provides valuable visual information about the patient's overall health status, potential abnormalities, and clues for further assessment. By taking time and paying attention to detail during inspection, the nurse can gather significant data that can guide the rest of the assessment process. The other choices are incorrect because: A) Inspecting usually yields valuable information, C) Discomfort is not a typical characteristic of the inspection phase, and D) Inspection requires thorough observation, not just a quick glance before palpation.
The nurse is conducting a pain assessment. Which question best evaluates the quality of the patient's pain?
- A. When did the pain start?
- B. What does the pain feel like?
- C. What makes the pain better or worse?
- D. Where is the pain located?
Correct Answer: B
Rationale: The correct answer is B: What does the pain feel like? This question is best for evaluating the quality of pain because it helps determine the characteristics and nature of the pain, such as sharp, dull, throbbing, burning, etc. Understanding the specific qualities of pain can provide valuable insights into possible causes and appropriate interventions.
A: When did the pain start? This question assesses the onset of pain, not its quality.
C: What makes the pain better or worse? This question evaluates exacerbating or alleviating factors, not the quality of pain.
D: Where is the pain located? This question assesses the location of pain, not its quality.
Which of the following is consistent with obturator sign?
- A. Pain distant from the site used to check rebound tenderness
- B. Right hypogastric pain with the right hip and knee flexed and the hip internally rotated
- C. Pain with extension of the right thigh while the patient is on her left side or while pressing her knee against your hand with thigh flexion
- D. Pain that stops inhalation in the right upper quadrant
Correct Answer: B
Rationale: The obturator sign is a test for appendicitis. B is correct because it describes the characteristic pain felt in the right hypogastric region when the right hip and knee are flexed and internally rotated, indicating irritation of the obturator muscle due to an inflamed appendix. A is incorrect as it describes rebound tenderness in a different location. C is incorrect as it describes pain with thigh extension or flexion, not internal rotation. D is incorrect as it describes pain that affects breathing, not related to obturator muscle irritation.