NCLEX Practice Questions Physical Assessment

Correct Answer: C

Rationale: To determine whether a murmur is systolic or diastolic, you should judge the relative length of systole and diastole by auscultation. Systolic murmurs occur during systole, which is the phase of the cardiac cycle when the heart is contracting and pushing blood out of the chambers. Diastolic murmurs occur during diastole, which is the phase when the heart is relaxing and filling with blood. By carefully listening to the timing of the murmur in relation to the cardiac cycle, you can determine if it is systolic or diastolic. Palpating the carotid pulse (Choice A) or radial pulse (Choice B) can help assess the pulse characteristics, but it does not directly determine whether a murmur is systolic or diastolic. Correlating the murmur with a bedside heart monitor (Choice D) may provide additional information about heart rate or rhythm, but it does not specifically indicate

Correct Answer: C

Rationale: A positive transillumination test is a key finding that would lead you to suspect a hydrocele as the cause of scrotal swelling. In a hydrocele, the scrotal fluid transilluminates well, meaning that when a light is shone through the scrotum, it will appear as a fluid-filled sac with a clear glow. This is a characteristic feature of a hydrocele and helps differentiate it from other causes of scrotal swelling, such as hernias or testicular tumors. Presence of bowel sounds in the scrotum (Choice A) would be concerning for a hernia rather than a hydrocele. Being unable to palpate superior to the mass (Choice B) may suggest a large hydrocele but is not specific to diagnosing a hydrocele. The normal thickness of the skin of the scrotum (Choice D) can be found in various scrotal conditions and is not specific

Correct Answer: C

Rationale: To determine whether a murmur is systolic or diastolic, you should judge the relative length of systole and diastole by auscultation. Systolic murmurs occur during systole, which is the phase of the cardiac cycle when the heart is contracting and pushing blood out of the chambers. Diastolic murmurs occur during diastole, which is the phase when the heart is relaxing and filling with blood. By carefully listening to the timing of the murmur in relation to the cardiac cycle, you can determine if it is systolic or diastolic. Palpating the carotid pulse (Choice A) or radial pulse (Choice B) can help assess the pulse characteristics, but it does not directly determine whether a murmur is systolic or diastolic. Correlating the murmur with a bedside heart monitor (Choice D) may provide additional information about heart rate or rhythm, but it does not specifically indicate

Correct Answer: D

Rationale: The most likely cause of the woman's symptom of stool leakage despite normal bowel movements is an anorectal fistula. An anorectal fistula is an abnormal, tunnel-like connection between the anal canal or rectum and the skin around the anus. In this case, the small opening anterior to the anus with surrounding erythema on examination suggests the presence of a fistula.

Correct Answer: D

Rationale: It is crucial to assess Adam's suicide risk immediately due to the statements he made about it being better if he were not here. This indicates possible suicidal ideation, which requires urgent attention and intervention. Asking directly about suicidal thoughts and intentions can help determine the level of risk and ensure that appropriate support and resources are provided to Adam. It is important to take any mention of suicide seriously and prioritize the safety and well-being of the individual in such situations.