Physical Assessment NCLEX Practice Questions

Correct Answer: C

Rationale: The described clinical presentation is consistent with internal hemorrhoids. The typical symptoms of internal hemorrhoids include painless rectal bleeding, protrusion from the anus during straining, and a feeling of incomplete evacuation. In this case, the protrusion is observed to be red, moist, and enlarges with bearing down, all indicative of internal hemorrhoids. The enlarged tender area felt on digital rectal examination supports the diagnosis. Additionally, the presence of blood on the glove after the examination is also suggestive of internal hemorrhoids causing bleeding. Anal fissures typically present with sharp pain during defecation and may have visible tears in the anal mucosa. External hemorrhoids are usually more painful and can be felt as a lump around the anus. Anorectal fistulas have different signs and symptoms, including discharge of pus and recurrent infections.

Correct Answer: B

Rationale: An ABI value less than 0.9 is indicative of mild peripheral arterial disease (PAD). In this case, an ABI of 0.85 falls below the 0.9 threshold, suggesting diminished blood flow to the lower extremities due to PAD. An ABI of 1.1 (Choice A) is actually elevated and not indicative of PAD. Values of 0.65 (Choice C) and 0.35 (Choice D) are significantly lower and would be consistent with moderate to severe PAD, rather than mild.

Correct Answer: C

Rationale: Beau's lines are transverse grooves or depressions in the nails that occur from a temporary disruption in nail growth. These lines can be caused by a variety of factors, including systemic diseases, medication use, trauma, or environmental stressors. However, one of the most common causes of Beau's lines is a significant physiological stress such as a severe illness or major surgery that occurred about 3 months prior to the appearance of the lines. Therefore, looking for information from family and records regarding any problems that occurred around 3 months ago is the most appropriate next step to understand the underlying cause of Beau's lines in this unconscious patient. This information can provide crucial insights into the patient's medical history and potential underlying health issues that may need to be addressed.

Correct Answer: C

Rationale: A dissecting aortic aneurysm is the most likely disorder that best describes the symptoms presented. In this condition, the inner layer of the aorta tears and blood can flow between the layers of the aortic wall, causing a number of potential symptoms. A patient with a dissecting aortic aneurysm may present with a difference in pulses between the right and left sides due to decreased blood flow to one side. The bounding pulse on one side and weak pulse on the other are indicative of uneven blood flow distribution. Additionally, a dissecting aortic aneurysm can lead to respiratory symptoms such as increased respiratory rate if there is associated pain or discomfort, although clear lung sounds would not typically be expected with this condition. The condition is a life-threatening emergency that requires immediate evaluation and treatment.

Correct Answer: B

Rationale: When a person's thought process is characterized by speaking rapidly, jumping from topic to topic, and making loose or tangential connections between ideas, it is referred to as a "flight of ideas." This type of thought process is commonly seen in conditions such as mania, where there is a marked increase in goal-directed activity, energy, and racing thoughts. In contrast, derailment refers to a disorganized thought process where the individual is unable to maintain a logical progression in their speech. Circumstantiality involves providing excessive and unnecessary detail before eventually reaching the main point. Incoherence is used to describe speech that is incomprehensible and disjointed, lacking any logical connection between ideas.