Chapter 12: Physical Assessment
During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Coughing d. Ecchymosis
NS: C Coughing is a sudden audible expulsion of air from the lungs. Coughing is an essential protective response that serves to clear the lungs, bronchi, or trachea of irritants and secretions or to prevent aspiration of foreign material into the lungs. It is a common sign of diseases of the larynx, bronchi, and lungs REF: Page 289, Table 12-1
OTHER 90. Arrange these assessment techniques in correct order of a standard physical examination. Put a comma and space between each answer choice (A, B, C, D, etc.). a. Auscultation b. Percussion c. Inspection d. Palpation
ANS: C, D, A, B The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion. REF: Page 293, Box 12-4
COMPLETION 71. The nurse notes that a patient has difficulty breathing in the supine position, and the patient admits that he sleeps in a recliner at home. These are cardinal signs of ____________ disease.
ANS: COPD pulmonary REF: Pages 304-305
_______________ _________and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle.
ANS: Cultural beliefs Cultural beliefs and personal characteristics determine health behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle. REF: Page 298
A condition in which there is a lack of appetite resulting in the inability to eat is known as _______________.
ANS: anorexia Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions. REF: Page 289, Table 12-1
The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of _________ ________.
ANS: arterial flow Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow. REF: Page 302
A condition of debility, loss of strength and energy, and depleted vitality is known as _________________.
ANS: asthenia Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. REF: Page 289, Table 12-1
A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as _________________.
ANS: bradycardia Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. REF: Page 289, Table 12-1
When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to ______________.
ANS: cough It is a useful assessment to determine that the patient can clear the secretions by coughing. REF: Page 305
A condition in which a patient experiences bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood is known as _________________.
ANS: cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. REF: Page 289, Table 12-1
Discoloration of an area of the skin or mucous membrane that is caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls is known as _________________.
ANS: ecchymosis Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into the subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls. REF: Page 289, Table 12-1
Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as _________________.
ANS: erythema Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries. REF: Page 289, Table 12-1
A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as ___________________.
ANS: jaundice Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. REF: Page 289, Table 12-1
Signs that are perceived by an examiner and can be seen, heard, measured, or felt are known as ___________ _________.
ANS: objective data Objective data is a sign that can be seen, heard, measured, or felt by the examiner. REF: Page 286
An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as ___________________.
ANS: orthopnea Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. REF: Page 289, Table 12-1
A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as _____________.
ANS: pruritus Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch REF: Page 290, Table 12-1
A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues is known as ___________ ___________.
ANS: purulent drainage Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. REF: Page 290, Table 12-1
Symptoms that are perceived by the patient are known as _____________ ____________.
ANS: subjective data Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data. REF: Page 287
A condition in which there is a temporary loss of consciousness associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of the skin is known as _________________.
ANS: syncope Syncope is a temporary loss of consciousness (partial or complete) associated with an increased rate of respiration, tachycardia, pallor, perspiration, and coolness of skin. REF: Page 301, Table 12-3
An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute is known as _______________
ANS: tachycardia Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats per minute. REF: Page 290, Table 12-1
An abnormally rapid rate of breathing that is seen in many disease conditions is known as ___________________.
ANS: tachypnea Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions. REF: Page 290, Table 12-1
An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment? a. Dehydration b. Edema c. Skin breakdown d. Malnutrition
ANS: A Dehydration results in decreased skin turgor. REF: Page 302
A nurse is caring for a patient with congestive heart failure. During the physical assessment, the nurse notes the patient is experiencing difficulty breathing. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
ANS: A Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety. REF: Page 289, Table 12-1
When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. How should the nurse document this finding? a. Skin pallor b. Pruritus c. Sallow skin d. Jaundice
ANS: A Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes. REF: Page 290, Table 12-1
There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic, physiological, age, and lifestyle. What is the term for these factors? a. Risk factors b. Causative factors c. Etiologic factors d. Hazardous factors
ANS: A Risk factors are placed into four categories. REF: Page 288
A physician documents that a patient has a sallow complexion. How does the nurse interpret this information? a. Yellow color to the skin b. Blue color to the skin c. Red color to the skin d. Gray color to the skin
ANS: A Sallow is an unhealthy, yellow color; usually said of a complexion or skin. REF: Page 290, Table 12-1
A physician documents that a patient has a scleral icterus. What is the cause of this coloring? a. Bilirubin b. Hemoglobin c. Serum potassium d. Serum magnesium
ANS: A Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. REF: Page 290, Table 12-1
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of chest pain b. Is experiencing dyspnea c. Appears to be anxious d. Expectorates red-tinged sputum
ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Chest pain is the only subjective assessment finding. All other options are examples of objective data. REF: Pages 287
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of diplopia b. Is experiencing nystagmus c. Demonstrates facial grimacing d. Has a generalized rash
ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data. REF: Pages 287
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data? a. Complains of pruritus b. Is experiencing erythema c. Appears to be experiencing pruritus d. Has a generalized rash
ANS: A Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Pruritus is the only subjective assessment finding. All other options are examples of objective data. REF: Pages 287
A patient has edema of the lower extremities. The nurse is assessing whether it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 2+ pitting edema. When did the edema disappear? a. 10-15 seconds b. 20-25 seconds c. 30-35 seconds d. 40-45 seconds
ANS: A The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds. REF: Page 110, Box 12-10
What should a patient interview being conducted by the nurse convey to the patient? a. The nurse has feelings of concern. b. The nurse has limited time. c. The nurse is very intelligent. d. The nurse has answers to problems.
ANS: A The nurse must convey feelings of concern. REF: Page 294
MULTIPLE RESPONSE 68. When assessing a female for risk factors associated with coronary artery disease, what information should the nurse include? (Select all that apply.) a. Family history of illness b. Diet c. Smoking d. Exercise e. Number of pregnancies
ANS: A, B, C, D With the exception of information relative to pregnancies, all options would be informative about risk for heart disease. REF: Page 288
The nurse is preparing to perform a physical assessment. What essential supplies should this nurse gather? (Select all that apply.) a. Flashlight b. Gloves c. Red pen d. Thermometer e. Scissors
ANS: A, B, D, E Items essential to the nurse's assessment are a penlight or flashlight, a stethoscope, a blood pressure cuff, a thermometer, gloves, gait belt, watch with second hand, scissors, black pen, and a tongue blade REF: Page 291, Box 12-2
Which are infectious diseases? (Select all that apply.) a. Measles b. Pneumonia c. Hay fever d. Tuberculosis e. Osteoarthritis f. Acquired immunodeficiency syndrome
ANS: A, B, D, F Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include acquired immunodeficiency syndrome (AIDS), tuberculosis, measles, and pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease. REF: Page 287
The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. What is this method? a. Nursing interview b. Review of systems c. Nursing assessment d. Health history
ANS: B A review of systems is a systematic method. REF: Page 296-297, Box
What type of disease results in a structural change in an organ that interferes with its functioning? a. Functional disease b. Organic disease c. Acute disease d. Chronic disease
ANS: B An organic disease results in a structural change in an organ. REF: Page 288
During a physical assessment, the nurse notes that a patient has bright red blood in the feces. What does the nurse recognize as the most likely cause of this bleeding? a. Bleeding in the upper intestinal tract b. Bleeding in the lower intestinal tract c. Bleeding in the entire intestinal tract d. Consumption of cranberry juice
ANS: B Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. REF: Page 289, Table 12-1
During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
ANS: B Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood. REF: Page 289, Table 12-1
When performing a physical examination of a patient, the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique? a. Auscultation b. Deep palpation c. Light palpation d. Percussion
ANS: B Deep palpation is used to detect tenderness or masses of the abdomen. REF: Page 309
The nurse is obtaining a history of a patient's present illness. The PQRST system is used for the interview. What does the R stand for in this system? a. Random b. Region c. Result d. Recent
ANS: B In the PQRST system, the R stands for region. REF: Page 295, Box 12-6
The signs and symptoms of both infection and inflammation include erythema, edema, and pain. What is considered the major difference between infection and inflammation? a. Inflammation is a result of bacteria. b. Inflammation is a protective response. c. Inflammation is a disease process. d. Inflammation produces tissue damage.
ANS: B Inflammation is a protective response. REF: Page 288
When assessing a patient with hepatitis, the nurse notes a yellow tinge to the patient's skin. What does the nurse understand as the most likely cause of the jaundice? a. Heart b. Liver c. Brain d. Intestines
ANS: B Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. REF: Page 289, Table 12-1
A physician needs to assess extension of a patient's hip joint. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent
ANS: B Prone position is used to assess extension of a patient's hip joint. REF: Page 292, Table 12-2
As part of an assessment, the nurse asks the patient for subjective information related to the present illness. What are the subjective findings perceived by the patient? a. Assessments b. Symptoms c. Signs d. Observations
ANS: B Symptoms are subjective indications of illness that are perceived by the patient. REF: Page 287
The nurse is meeting a patient for the first time. What is the first thing the nurse will do to initiate a nurse-patient relationship? a. Appear interested b. Introduce herself/himself c. Provide support d. Communicate trust
ANS: B The first step in a nurse-patient relationship is for the nurse to introduce herself/himself. REF: Page 293-294
What does the nurse recognize as the initial step in conducting an assessment of a patient? a. A body systems review b. The nursing health history c. Biographical data d. The present illness
ANS: B The nursing health history is the initial step in the assessment process. REF: Page 295
tating the thorax? a. Anterior thorax b. Apices c. Left lateral thorax d. Right lateral thorax
ANS: B The suggested sequence for a systematic auscultation of the thorax is to begin with the apices. REF: Page 304
When performing a nursing physical assessment, the nurse uses a head-to-toe approach. Where will the nurse begin when using this method? a. Skin assessment b. Neurologic assessment c. Circulatory assessment d. Respiratory assessment
ANS: B When performing a head-to-toe assessment, the nurse begins with a neurologic assessment. REF: Page 300, Box 12-8,
A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require? a. Individualized b. Focused c. Specialized d. Systematic
ANS: B When the nurse observes a change in the patient's condition, the assessment is focused. REF: Page 298
Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition? a. Injury b. Condition c. Disease d. Pathology
ANS: C A disease is any disturbance of a structure or function of the body. REF: Page 287
MULTIPLE CHOICE 1. The nurse is collecting data during an initial assessment. What can be seen, heard, measured, or felt and is objective? a. Symptom b. Observation c. Sign d. Assessment
ANS: C A sign can be seen, heard, measured, or felt. REF: Page 286
During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Asthenia c. Anorexia d. Ecchymosis
ANS: C Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions. REF: Page 289, Table 12-1
During a physical assessment, the nurse notes a patient has a loss of strength and energy. What should the nurse document that the patient is experiencing?
ANS: C Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. REF: Page 289, Table 12-1
The nurse assesses a patient for capillary refill after the fingernail is compressed for 5 seconds. What should the nurse expect the refill time to be? a. 1 second b. 2 seconds c. 3 seconds d. 4 seconds
ANS: C Capillary refill should take fewer than 3 seconds. REF: Page 308
During a physical assessment, the patient complains of difficulty in passing stools. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Constipation d. Ecchymosis
ANS: C Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional REF: Page 289, Table 12-1
During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse. When are these sounds most often auscultated? a. During expiration b. Following expiration c. During inspiration d. Following inspiration
ANS: C Crackles are usually heard during inspiration. REF: Page 304
When discussing diabetes with a patient, the nurse describes this disease as falling into which group in terms of duration? a. Acute b. Organic c. Chronic d. Functional
ANS: C Diabetes mellitus is an example of a chronic disease.REF: Page 288
The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease? a. Pituitary b. Adrenals c. Pancreas d. Thyroid
ANS: C Diabetes mellitus results from dysfunction of the pancreas. REF: Page 287
During a physical assessment, the nurse notes a patient has profuse secretions of sweat. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
ANS: C Diaphoresis is the secretion of sweat, especially the profuse secretion associated with an elevated body temperature, physical exertion, exposure to heat, and mental or emotional stress. REF: Page 289, Table 12-1
When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Erythema d. Ecchymosis
ANS: C Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries; erythema is seen in mild sunburn. REF: Page 289, Table 12-1
When assessing a patient, the nurse notes a yellow tinge to the patient's skin. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Ecchymosis
ANS: C Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver. REF: Page 289, Table 12-1
A nurse needs to auscultate a patient's lung sounds. In what position should the nurse place the patient? a. Sims b. Prone c. Sitting d. Lithotomy
ANS: C Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. REF: Page 292, Table 12-2
Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope. What causes the "lubb" sound? a. Opening of the AV valves b. Opening of the semilunar valves c. Closing of the AV valves d. Closing of the semilunar valves
ANS: C The "lubb-dupp" sound of the heart is caused by the closing of the AV and semilunar valves, respectively. REF: Page 305-306
When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data. What does this data help to establish? a. A nursing diagnosis b. A nursing care plan c. Appropriate interventions d. Nursing orders
ANS: C The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions. REF: Page 296
A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for: a. a complete physical examination. b. a medical assessment. c. an individualized plan of care. d. writing nursing orders.
ANS: C The information contained in the database is the basis for an individualized plan of care. EF: Page 290
A physician needs to insert a vaginal speculum into a patient for a vaginal examination. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Dorsal recumbent
ANS: C The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum. REF: Page 292, Table 12-2
Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. What is the normal rate of bowel sounds per min-ute? a. 2-10 b. 3-20 c. 4-32 d. 5-40
ANS: C The normal rate of bowel sounds per minute is 4 to 32. REF: Page 308
During the nursing interview, several histories are taken. What is the history that involves data concerning habits and lifestyle patterns? a. Family history b. Environmental history c. Past health history d. Psychosocial history
ANS: C The nurse identifies habits and lifestyle patterns under the past health history. REF: Page 296
During a neurologic assessment, the nurse notes a patient has a unilateral, dilated, and nonreactive pupil. This is a sign that the patient is experiencing pressure on which cranial nerve? a. I b. II c. III d. IV
ANS: C The third cranial nerve runs parallel to the brainstem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brainstem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil. REF: Page 301
During a physical assessment, the nurse notes that a patient's heart rate is 56 beats per minute. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Bradycardia
ANS: D Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. REF: Page 289, Table 12-1
During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Diarrhea
ANS: D Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. REF: Page 289, Table 12-1
A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. What should the nurse document that the patient has? a. Dyspnea b. Cyanosis c. Diaphoresis d. Ecchymosis
ANS: D Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise). REF: Page 289, Table 12-1
A physician needs to assess a patient's rectal area. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Knee-chest
ANS: D Knee-chest position provides maximum exposure of the rectal area. REF: Page 292, Table 12-2
The nurse is assessing a patient for collection of subjective and objective data. What will this data provide the basis for making? a. Care plan b. Medical diagnosis c. Nursing assessment d. Nursing diagnosis
ANS: D Nurses rely on assessment of signs and symptoms to formulate a nursing diagnosis. REF: Page 287
A nurse is gathering objective data when admitting a patient. Which assessment finding reported by the patient is considered objective? a. Complains of nausea b. States, "I hurt all over." c. Complains of feeling anxious d. Appears to be anxious
ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Anxiety is the only objective assessment finding. All other options are examples of subjective data. REF: Page 286
A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective data? a. The patient complains of chest pain. b. The patient states, "I am having trouble breathing." c. The patient complains of coughing up sputum. d. The patient expectorates red-tinged sputum.
ANS: D Objective data can be seen, heard, measured, or felt by the examiner. It is information that is observable and measurable and can be verified by more than one person. Expectoration of red-tinged sputum is the only objective assessment finding. All other options are examples of subjective data. REF: Page 286
When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient into a sitting position, the patient is able to breathe more easily. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Jaundice d. Orthopnea
ANS: D Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably. It occurs in many disorders of the respiratory and cardiac systems. REF: Page 289, Table 12-1
When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratches frequently. How should the nurse document this finding? a. Dyspnea b. Cyanosis c. Jaundice d. Pruritus
ANS: D Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch. Some causes are allergy, infection, jaundice, elevated serum urea, and skin irritation. REF: Page 290, Table 12-1
A physician documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause? a. Ringworm b. Viral infection c. Fungal infection d. Bacterial infection
ANS: D Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance. REF: Page 290, Table 12-1
What is the term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease? a. Acute b. Functional c. Chronic d. Remission
ANS: D Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. REF: Page 288
A physician documents that a patient has a scleral icterus. How does the nurse describe the color of the patient's sclera? a. Red b. Blue c. Green d. Yellow
ANS: D Scleral icterus means the color of the sclera is yellow. The jaundice is due to coloring of the sclera with bilirubin that infiltrates all tissues of the body. EF: Page 290, Table 12-1
The nurse is performing auscultation of breath sounds on a respiratory patient. The sounds heard on inspiration and expiration are low-pitched, coarse, gurgling, and have a snoring sound. What best identifies these sounds? a. Crackles b. Plural friction rub c. Rhonchi d. Sonorous wheezes
ANS: D Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airway REF: Page 304
The patient should be assessed as soon as possible after admission. Who performs this initial assessment? a. Physician b. Charge nurse c. LPN/LVN d. RN
ANS: D The initial assessment is done by the registered nurse. REF: Page 298
A physician needs to assess a patient for a heart murmur. In what position should the nurse place the patient? a. Sims b. Prone c. Lithotomy d. Lateral recumbent
ANS: D The lateral recumbent position aids in detecting heart murmurs. REF: Page 292, Table 12-2
The nurse is developing a nursing care plan for a newly admitted patient. What is the first step the nurse will take in developing this care plan? a. Health history b. Review of systems c. Family history d. Nursing assessment
ANS: D The nursing assessment is the critical step in forming the nursing care plan. REF: Page 298
Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. What is percussion used to determine? a. Sounds for auscultation b. Data about physical features c. Changes in structural integrity d. Density of underlying tissue
ANS: D The sounds indicate the density of the underlying tissue. REF: Page 293, Box 12-4
What should the nurse begin by assessing when performing a head-to-toe assessment? a. Support system b. Skin integrity c. Pain level d. Neurologic status
ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. REF: Page 300, Box 12-8
During a head-to-toe assessment, the nurse assesses the patient's perineal area. Which area should the nurse assess next? a. Chest b. Arms c. Abdomen d. Legs and feet
ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. REF: Page 300, Box 12-8;
During a head-to-toe assessment, the nurse assesses the patient's abdomen. Which area should the nurse assess next? a. Chest b. Arms c. Legs and feet d. Perineal area
ANS: D When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order. REF: Pages 300, Box 12-8; 309-310
