Nokea
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.
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In performing a breast examination, the nurse knows that examining the upper outer quadrant of the breast is especially important. The reason for this is that the upper outer quadrant is:
- A. The largest quadrant of the breast.
- B. The location of most breast tumors.
- C. Where most of the suspensory ligaments attach.
- D. More prone to injury and calcifications than other locations in the breast.
Correct Answer: B
Rationale: The correct answer is B: The location of most breast tumors. This is because statistically, the upper outer quadrant of the breast is where the majority of breast tumors are found. This area is more glandular and has more breast tissue, making it a common site for tumors to develop. It is important to focus on this area during a breast examination to detect any abnormalities early.
A: The largest quadrant of the breast - This is not the reason why examining the upper outer quadrant is important for detecting breast tumors.
C: Where most of the suspensory ligaments attach - While true, this is not the primary reason for focusing on the upper outer quadrant during a breast examination.
D: More prone to injury and calcifications than other locations in the breast - While calcifications can occur in this area, it is not the primary reason for its importance in detecting breast tumors.
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.
What would a nurse ensure before beginning a health assessment?
- A. that the time needed for the assessment fits into the nurses work schedule
- B. that the room is private, quiet, warm, and has adequate light
- C. that family members are present to answer specific questions
- D. that there is a written physicians order for the assessment
Correct Answer: B
Rationale: A private, quiet, warm, well-lit room , per the answer key, ensures comfort and accuracy. Scheduling , family presence , or physician orders are secondary or unnecessary. Nurses, per Taylor, create optimal environments for effective assessments.
What provocative maneuver is used to test for lateral epicondylitis?
- A. Empty can test
- B. Valgus stress test
- C. Elbow flexion test
- D. Cozen's test
Correct Answer: D
Rationale: The correct answer is D: Cozen's test. This test is used to assess for lateral epicondylitis by asking the patient to make a fist, pronate the forearm, radially deviate the wrist, and extend the elbow against resistance. Pain over the lateral epicondyle indicates a positive test. The other choices are incorrect because:
A: Empty can test is used to assess for supraspinatus tendon injury.
B: Valgus stress test is used to assess for medial collateral ligament injury of the elbow.
C: Elbow flexion test is not a specific test for lateral epicondylitis.
The nurse is performing a neurological assessment and notes a positive Romberg test. What does this finding indicate?
- A. Cranial nerve dysfunction.
- B. Cerebellar ataxia or vestibular dysfunction.
- C. Peripheral neuropathy.
- D. Increased intracranial pressure.
Correct Answer: B
Rationale: The Romberg test assesses balance and postural stability. A positive Romberg test indicates a deficit in proprioception, which is commonly seen in cerebellar ataxia or vestibular dysfunction. The cerebellum and vestibular system play crucial roles in maintaining balance and coordination. Cranial nerve dysfunction (A) does not directly affect balance. Peripheral neuropathy (C) primarily affects sensation and motor function, not balance. Increased intracranial pressure (D) may present with other neurological signs, but not specifically a positive Romberg test. Therefore, the correct answer is B.