Chapter 13 - Physical Assessment

Abnormal swishing sounds heard over organs, glands and arteries and results from an abnormality in an artery resulting from narrow or partially occluded artery such as those in atherosclerosis

bruit

68. What is the third assessment technique in a standard physical examination? a. Auscultation b. Percussion c. Inspection d. Palpation

a. Auscultation The usual sequence of assessment: - inspection -palpation -auscultation -percussion.

1. An unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings is ___________.

pain Pain is an unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings. It is a cardinal symptom of inflammation and is valuable in the diagnosis of many disorders and conditions. Pain has varied manifestations: mild or severe, chronic, acute, burning, dull or sharp, precisely or poorly localized, or referred.

14. A symptom of itching and an uncomfortable sensation leading to an urge to scratch is known as _____________.

pruritus Pruritus is a symptom of itching and an uncomfortable sensation leading to an urge to scratch.

An abnormal cycle of respiration that begin with slow, shallow respiration that become rapid, then become slower and are followed by periods of apnea (20 seconds). Normally caused by hear failure, opioid overdose, renal failure, meningitis, and severe head ache.

Cheyne-stokes

67. A health care provider 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

a. Bilirubin 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.

21. 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

b. Neurologic assessment 1. Neurological 2. Integumentary 3. Cardiovascular 4. Respiratory 5. GI 6. GU 7. Mobility Follow: -skin -hair -head and neck -chest -back -arms -abdomen -perineal area -legs and feet pg. 325 Box 13.8

27. 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 to 15 seconds b. 20 to 25 seconds c. 30 to 35 seconds d. 40 to 45 seconds

a. 10 to 15 seconds The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds. 1+: Trace: 2mm 2+: Mild: 4mm: 10-15 secs 3+: Moderate: 6mm: 30 secs - 1 min 4+: Severe: 8mm: 2-5 mins pg. 334

35. 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.

a. Complains of chest pain. 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.

37. 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

a. Complains of diplopia 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.

36. 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.

a. Complains of pruritus. 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.

22. 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

a. Dehydration Dehydration: decreased skin turgor. (tenting) edema: increased skin turgor: (smooth, taut, shiny skin that cannot be grasped and raised.) Turgor: elasticity of the skin pg. 327

56. 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

a. Dyspnea Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety. pg. 314

1. 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

a. Family history of illness b. Diet c. Smoking d. Exercise With the exception of information relative to pregnancies, all options would be informative about risk for heart disease.

3. 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

a. Flashlight b. Gloves d. Thermometer e. Scissors Items essential to the nurse's assessment are -penlight or flashlight -stethoscope -blood pressure cuff -thermometer -gloves -gait belt -watch with second hand -scissors, black pen -tongue blade pg. 316

2. Which are infectious diseases? (Select all that apply.) a. Measles b. Pneumonia c. Hay fever d. Tuberculosis e. Osteoarthritis f. Acquired immunodeficiency syndrome

a. Measles b. Pneumonia d. Tuberculosis f. Acquired immunodeficiency syndrome Infectious diseases result from the invasion of microorganisms into the body. Examples of infectious diseases include: -acquired immunodeficiency syndrome (AIDS) -tuberculosis -measles -pneumonia. Hay fever is a manifestation of an allergic reaction, and osteoarthritis is an example of a degenerative disease.

6. There are four categories of factors that increase an individual's vulnerability to develop a disease: genetic, physiologic, age, and lifestyle. What is the term for these factors? a. Risk factors b. Causative factors c. Etiologic factors d. Hazardous factors

a. Risk factors -Genetic and Physiologic: Hx of Ca, malnourishment -Age: Osteoporosis, thinning of skin -Environment: Pollution, CO, Extreme temp, high crime, overcrowding, family -Lifestyle: poor Habits, overeating, poor nutrition, stress, smoking, sunbathing Pg 313

62. 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

a. Skin pallor Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.

13. 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.

a. The nurse has feelings of concern. Convey feelings of compassion and concern at the same time Remain objective nurse demonstrates interest in patient's state of wellness conduct interview in a -relaxed (eye level, accepting posture) -unhurried manner -quiet -well-lighted setting pg. 319

65. A health care provider 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

a. Yellow color to the skin Sallow is an unhealthy, yellow color; usually said of a complexion or skin. pg. 315

44. A health care provider 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

d. Lateral recumbent The lateral recumbent position aids in detecting heart murmurs. *Heart patients with respiratory difficulties tolerate this very poorly pg. 317

6. A condition in which there is a lack of appetite resulting in the inability to eat is known as _______________.

anorexia Anorexia is a lack of appetite resulting in the inability to eat. It can occur in many disease conditions.

7. A condition of debility, loss of strength and energy, and depleted vitality is known as _________________.

asthenia Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.

32. What is the suggested sequence for a systematic approach to begin auscultating the thorax? a. Anterior thorax b. Apices c. Left lateral thorax d. Right lateral thorax

b. Apices The suggested sequence for a systematic auscultation of the thorax is to begin with the apices and the posterior, lateral, and anterior chest. Use the ZigZag approach, comparing the findings at each point with the corresponding point on the opposite side. pg. 328

55. 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

b. Bleeding in the lower intestinal tract Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract. pg. 314

47. 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

b. Cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

30. 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

b. Deep palpation Deep palpation: -is used to detect tenderness or masses of the abdomen. light palpation: -enables the nurse to detect superficial lesion just below the skin Assessment: -Inspection -Auscultation -palpation -percussion pg. 333

20. 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

b. Focused When the nurse observes a change in the patient's condition, the assessment is focused. -attention is concentrated or focused on a particular part of the body pg 324

10. 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.

b. Inflammation is a protective response. infection: caused by invasion of microorganism, such as bacteria, viruses, fungi, or parasites that produce tissue damage. Inflammation: is a protective response of body tissues to irritation, injury, or invasion by disease-producing organisms. CARDINAL SIGNS: -Erythema (redness) -edema (swelling) -heat, pain -purulent (pus) -loss of function pg. 314

12. 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.

b. Introduce herself/himself. The first step in a nurse-patient relationship is for the nurse to introduce herself/himself. is the nurse's first task to establish an effective nurse-patient relationship before proceeding to the nursing health history -name -position -purposes of the interview pg. 317

59. 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

b. Liver Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

9. 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

b. Organic disease An organic disease results in a structural change in an organ. Chronic: develops slowly and persists over a long period, lifetime Acute: begins abruptly with marked intensity of severe signs and symptoms, subsides after treatment Functional: appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities. Many nervous and mental disease are classified Ex. Fibromyalgia, IBS. CFS, GERD, TMJ, Interstitial cystitis, pruritus. pg. 313

43. A health care provider 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

b. Prone Prone position is used to assess extension of a patient's hip joint *musculoskeletal system patients with respiratory difficulties tolerate this very poorly pg. 317

29. 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

b. Region In the PQRST system, the R stands for region. Where is it? Does it spread? Does it travel? P: Precipating-provocative-palliative Q: Quality-Quantity R: Region-Radiation S: Severity scale T: Treatments pg. 320

17. 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

b. Review of systems A review of systems is a systematic method for collecting data of all body systems Usually subjective: how patient perceives it pg. 322

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

b. Symptoms Symptoms are subjective indications of illness that are perceived by the patient. Ex. Pain, nausea, vertigo, pruritus, diplopia (double vision), numbness and anxiety Examples: "I feel like a knife is stabbing me in my stomach" pg. 312

14. 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. Biographic data d. The present illness

b. The nursing health history The nursing health history is the initial step in the assessment process. -level of wellness -changes in life patterns -sociocultural role -mental and emotional reactions to illness pg. 319

8. A circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute is known as _________________.

bradycardia Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute.

25. 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

c. 3 seconds Capillary refill should take fewer than 3 seconds. press firmly for 5 secs on fingernail or toe nail and estimate speed at which blood returns *tips for the fingers and toes can be used if the person has thick, unbalanceable nail beds more than 3 secs is consider sluggish digital circulation refill of 5 secs: abnormal Ex. dehydration, PVD, poor cardiac function pg. 332

26. 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 minute? a. 2 to 10 b. 3 to 20 c. 4 to 32 d. 5 to 40

c. 4 to 32 The normal rate of bowel sounds per minute is 4 to 32. listen to BM sounds 1 min in all 4 quadrants At least 4 mins before concluding NO BM sounds Bowel sounds: -Active: q15-60 secs -Hyperactive -Hypoactive: absent Supine with knees elevated interview: -expelling of flatus -latest BM -reports of N/V -altered or decreased appetite (anorexia) Assessment: -Inspect -auscultate -palpate -percuss pg. 332

48. 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

c. Anorexia Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions. pg. 314

15. 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 patient problem b. A nursing care plan c. Appropriate interventions d. Nursing orders

c. Appropriate interventions The data collected related to the present illness must be detailed and comprehensive to allow planning of appropriate interventions.

49. 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? a. Dyspnea b. Cyanosis c. Asthenia d. Ecchymosis

c. Asthenia Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. pg. 314

40. 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

d. Legs and feet 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. pg. 325

7. 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

c. Chronic Diabetes mellitus (inability of the body to use glucose) is an example of a chronic disease. Disease develops slowly and persists over a long period. is frequently described further as early, late, or terminal or on remission. Acute: begins abruptly with marked intensity of severe signs and symptoms and often subsides after a period of treatment Ex. Appendicitis Organic: structural change in an organ that interferes with its functioning. Ex. Stroke, Alzheimer's Functional: appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities. Many nervous and mental disease are classified Ex. Fibromyalgia, IBS. CFS, GERD, TMJ, Interstitial cystitis, pruritus. pg. 313

24. Auscultating the heart sounds should result in a "lub-dub" sound when using the bell and the diaphragm of the stethoscope. What causes the "lub" 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

c. Closing of the AV valves The "lub-dub" sound of the heart is caused by the closing of the AV and semilunar valves, respectively. S1: Lub: Closure of the atrioventricular valves; beginning of systole: hear at the apex S2: Dub: closure of the semilunar valve: end of systole: hear at the base pg. 330

51. 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

c. Constipation Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional. pg. 314

52. 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

c. Coughing 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. pg. 314

53. 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

c. Diaphoresis 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 pg. 314

3. 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

c. Disease A disease is any disturbance of a structure or function of the body. Signs and symptoms characterize a disease. hereditary, congenital, inflammatory, degenerative, infectious, deficiency, metabolic, neoplastic, traumatic, environmental, or a combination of these. pg. 312

23. 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

c. During inspiration Crackles produced by fluid in the bronchioles and the alveoli, are short, discrete, interrupted, crackling, or bubbling sounds that are usually heard during inspiration. -Fine -Medium -Coarse pg. 329

58. 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

c. Erythema 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. pg. 314

41. 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

c. III 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. cranial nerve assessment (performed by the RN) pg. 325

60. 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

c. Jaundice Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

42. A health care provider 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

c. Lithotomy The lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum. *female genitalia and genitalia tract Sims: enema Dorsal Recumbent: Supine, knees flexed pg. 317

5. 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

c. Pancreas Diabetes mellitus is a metabolic disease that is a dysfunction that involves the endocrine glands, which secrete hormones to regulate body process. this results is a dysfunction of the pancreatic islets.

16. 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

c. Past health history The nurse identifies habits and lifestyle patterns under the past health history. use of ETOH, tobacco, illegal drugs, caffeine, herbal products, or OTC drugs or Rx meds ADL patterns, sleep, exercise.,nutrition pg. 320

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

c. Sign A signs are objective: can be -seen -heard -measured -felt. Ex: rashes, altered vital signs, abnormal lung or heart sounds visible drainage: passive or active removal of fluids from body cavity or wound or other source of discharge Ex: closed urinary drainage system or open drainage system (Jackson-Pratt drain) visible exudate: fluids, cells, or other substances Ex. results from inflammation or injury, perspiration, pus, and serum Lab findings and diagnostic imaging and other diagnostic studies. pg. 312

46. 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

c. Sitting Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts. pg. 317

11. 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.

c. an individualized plan of care. The information contained in the database is the basis for an individualized plan of care throughout the nursing process -gathering -verifying -communicating of data about the patient *establish a baseline Data collected during this process include: -health history -physical examination -results of labs and diagnostic tests -Information from health care team members -patient's family or significant others pg. 316

2. When auscultating the chest, a nurse hears crackles in both lower lobes. To further assess this finding, the nurse should ask the patient to ______________.

cough It is a useful assessment to determine that the patient can clear the secretions by coughing.

9. 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 _________________.

cyanosis Cyanosis is a bluish discoloration of the skin and mucous membranes caused by an increase of deoxygenated hemoglobin in the blood.

33. 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

d. Appears to be anxious 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.

64. A health care provider 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

d. Bacterial infection 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.

50. During a physical assessment, the nurse notes that a patient's heart rate is 56 beats/min. What should the nurse document that the patient is experiencing? a. Dyspnea b. Cyanosis c. Diaphoresis d. Bradycardia

d. Bradycardia Bradycardia is a circulatory condition in which the myocardium contracts steadily but at a rate of less than 60 contractions per minute. pg. 314

28. 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

d. Density of underlying tissue The sounds indicate the density of the underlying tissue. -Fingertips to tap the body's surface: place palmer surface of the hand, tap with fingers -Indicate density, help locate organs · Tympany: hollow organ (stomach) high pitched sound · Dullness: Dense organ (liver) Low pitched sound · Flatness: over muscle: soft high pitched flat sound pg. 317

54. 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

d. Diarrhea 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. pg. 314

57. 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

d. Ecchymosis 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). pg. 314

45. A health care provider 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

d. Knee-chest Knee-chest position provides maximum exposure of the rectal area. *Rectum and vagina joint deformities may hinder ability to bend hip and knee pg. 317

38. 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

d. Neurologic status 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. pg. 325

18. 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

d. Nursing assessment -gathering -verifying -communicating of data Establish a baseline pg. 316

61. 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

d. Orthopnea 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. pg. 315

4. 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. Patient problem

d. Patient problem Nurses rely on assessment of signs and symptoms to formulate a patient problem statement. Patient problem statement recognizes the holistic needs of the patient that will be treated with nursing interventions. some interventions are made independently nurse depends on or collaborates with other members of the health care team. -gathering -verifying -communicating *establish a baseline **determine the actual or potential (risk for) patient problems that will require interventions for safety and well-being of the patient pg. 312

39. 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

d. Perineal area 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. pg. 325

63. 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

d. Pruritus 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.

19. The patient should be assessed as soon as possible after admission. Who performs this initial assessment? a. Health care provider b. Charge nurse c. LPN/LVN d. RN

d. RN -complete within 24 hrs of admission -head-to-toe -ongoing assessment is the responsibility of the RN and LPN pg. 324

8. 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

d. Remission Remission means there has been partial or complete disappearance of the clinical and subjective characteristics. Chronic: develops slowly and persists over a long period, lifetime Acute: begins abruptly with marked intensity of severe signs and symptoms, subsides after treatment Functional: appear to be those of organic disease, but careful examination fails to reveal evidence of structural or physiologic abnormalities. Many nervous and mental disease are classified Ex. Fibromyalgia, IBS. CFS, GERD, TMJ, Interstitial cystitis, pruritus. pg. 313

31. 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

d. Sonorous wheezes -Sonorous wheezes: have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways. clear, at least somewhat with cough -Crackles: fluid in bronchioles and the alveoli -Plural friction rub: inflammation of the pleural sac; rubbing, grating, or squeaky -Rhonchi: rattling sounds pg. 328-329

34. 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.

d. The patient expectorates red-tinged sputum. Objective data can be seen, heard, measured, or felt by the examiner. It is information that isobservable 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.

66. A health care provider 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

d. Yellow 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.

10. 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 _________________.

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.

11. Redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries is known as _________________.

erythema Erythema is redness or inflammation of the skin or mucous membranes that is the result of dilation and congestion of superficial capillaries.

3. The nurse observes that an older adult patient has no hair on the lower legs. The nurse should assess further for the sufficiency of arterial ________.

flow Reduced arterial flow causes lack of hair on the lower extremities due to inadequate blood flow. PAD (peripheral artery disease): No O2 traveling to lower legs A: absent pulses: Absent hair (shiny): cool legs R: round, red sores T: toes and feet pale (black eschar) S: sharp pain on calf (intermittent claudication)

19. Cultural beliefs and personal characteristics determine __________ behavior in individuals and families. More than half of all health problems are the result of behavior and lifestyle.

health 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.

4. Signs that are perceived by an examiner and can be seen, __________, measured, or felt are known as objective data.

heard Objective data is a sign that can be seen, heard, measured, or felt by the examiner.

12. A yellow tinge to the skin that may indicate obstruction in the flow of bile from the liver is known as ___________________.

jaundice Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.

13. An abnormal condition in which a person must sit or stand to breathe deeply or comfortably is known as ___________________.

orthopnea Orthopnea is an abnormal condition in which a person must sit or stand to breathe deeply or comfortably.

5. Symptoms that are perceived by the patient are known as _____________ data.

subjective Symptoms are subjective indications of illness that are perceived by the patient. Symptoms are referred to as subjective data.

18. 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 _________________.

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.

16. An abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min is known as ___________________.

tachycardia Tachycardia is an abnormal condition in which the heart contracts regularly but at a rate greater than 100 beats/min.

17. An abnormally rapid rate of breathing that is seen in many disease conditions is known as ___________________.

tachypnea Tachypnea is an abnormally rapid rate of breathing that is seen in many disease conditions.

15. A creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of __________ is known as purulent drainage.

tissues 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.