Ch 05: Physical Assessment

78. 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 96, Table 5-1 TOP: Bradycardia

74. 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 93 TOP: Objective data

73. Arrange these assessment techniques in correct order of a standard physical examination. 1. Auscultation 2. Percussion 3. Inspection 4. Palpation Put a comma between each answer choice (1, 2, 3, 4, etc.).

ANS: 3, 4, 1, 2 3,4,1,2 The usual sequence of assessment is inspection, palpation, auscultation, and lastly percussion. REF: Page 100, Box 5-4 TOP: Physical examination series

70. 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 Long-term pulmonary disease makes it difficult for the patient to breathe without distress in the supine position. They frequently sleep in a recliner chair. REF: Pages 110-111 TOP: Chest assessment

76. A condition is 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 96, Table 5-1 TOP: Anorexia

72. The nurse observes 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 109 TOP: Vascular assessment

77. 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 96, Table 5-1 TOP: Asthenia

71. 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 112 TOP: Crackles

79. 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 96, Table 5-1 TOP: Cyanosis

80. 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 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 96, Table 5-1 TOP: Ecchymosis

81. 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 96, Table 5-1 TOP: Erythema

82. 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 96, Table 5-1 TOP: Jaundice

83. 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 96, Table 5-1 TOP: Orthopnea

84. 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 96, Table 5-1 TOP: Pruritus

85. 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 96, Table 5-1 TOP: Purulent drainage

75. 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 93 TOP: Subjective data

88. 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 108, Table 5-3 TOP: Syncope

86. 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 96, Table 5-1 TOP: Tachycardia

87. 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 96, Table 5-1 TOP: Tachypnea

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. The nurse recognizes this could be caused by: a. dehydration. b. edema. c. skin breakdown. d. malnutrition.

ANS: A Dehydration results in decreased skin turgor. REF: Page 109 TOP: Assessment

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. The nurse should 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 96, Table 5-1 TOP: Assessment

62. When assessing a patient, the nurse notes that the patient has an unnatural paleness of color to the skin. The nurse should document this finding as: 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 96, Table 5-1 TOP: Assessment

6. There are four categories of factors that increase an individual's vulnerability to developing a disease: genetic, physiological, age, and lifestyle. These are called: a. risk factors. b. causative factors. c. etiological factors. d. hazardous factors.

ANS: A Risk factors are placed into four categories. REF: Page 95 TOP: Disease Step: Evaluation

65. A physician documents that a patient has a sallow complexion. The nurse understands that this means the patient has a: 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 96, Table 5-1 TOP: Assessment

67. A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient's sclera is yellow and is caused by infiltration of: 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 96, Table 5-1 TOP: Assessment

20. A patient was admitted with a complaint of abdominal pain. Later, the nurse observed the patient demonstrating dyspnea. This change in condition requires an assessment called: 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 106 TOP: Assessment

35. A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient: 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 93-94 TOP: Assessment

37. A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient: 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 93-94 TOP: Assessment

36. A nurse is gathering subjective data when admitting a patient. Which assessment finding is considered subjective data? The patient: 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. Pruritis is the only subjective assessment finding. All other options are examples of objective data. REF: Pages 93-94 TOP: Assessment

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 because the edema disappears in: 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 117, Box 5-11 TOP: Assessment

13. A patient interview being conducted by the nurse should convey to the patient that the nurse has: a. feelings of concern. b. plenty of time. c. a lot of information. d. the answers to problems.

ANS: A The nurse must convey feelings of concern. REF: Page 101 TOP: Interview

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 95 TOP: Risk factors

69. 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 94 TOP: Infectious diseases

59. When assessing a patient with hepatitis, the nurse notes a yellow tingle to the patient's skin. The nurse understands that jaundice most likely results from an obstruction in the flow of bile from the: 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 96, Table 5-1 TOP: Assessment

17. The nurse uses a systematic method for collecting data on all body systems, including normal functioning and any noted changes. This method is a: 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 104 TOP: Interview

9. When a disease results in a structural change in an organ that interferes with its functioning, this is a(n): 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 95 TOP: Disease

55. During a physical assessment, the nurse notes that a patient has bright red blood in the feces. The nurse recognizes that the bleeding is most likely caused by: 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 96, Table 5-1 TOP: Assessment

47. During a physical assessment, the nurse notes a patient has a bluish discoloration of the skin and mucous membranes. The nurse should document that the patient is experiencing: 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 96, Table 5-1 TOP: Assessment

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. This technique is: 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 116 TOP: Assessment

29. The nurse is obtaining a history of a patient's present illness. The PQRST system is used for the interview. In this system, the R stands for: a. random. b. region. c. result. d. recent.

ANS: B In the PQRST system, the R stands for region. REF: Page 102, Box 5-6 TOP: Assessment

10. Although the signs and symptoms of both infection and inflammation include erythema, edema, and pain, the major difference is that inflammation: a. is a result of bacteria. b. is a protective response. c. is a disease process. d. produces tissue damage.

ANS: B Inflammation is a protective response. DIF: Cognitive Level: Assessment REF: Page 95 TOP: Disease

43. A physician needs to assess extension of a patient's hip joint. The nurse should place the patient in what position? 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 99, Table 5-2 TOP: Assessment

2. As part of an assessment, the nurse asks the patient for subjective information related to the present illness. Subjective findings that are perceived by the patient are known as: a. assessments. b. symptoms. c. signs. d. observations.

ANS: B Symptoms are subjective indications of illness that are perceived by the patient. REF: Page 93 TOP: Assessment

12. The nurse is meeting a patient for the first time. The initial step when initiating a nurse-patient relationship is for the nurse to: a. appear interested. b. introduce her/himself. c. provide support. d. communicate trust.

ANS: B The first step in a nurse-patient relationship is for the nurse to introduce her/himself. REF: Page 100 TOP: Nurse-patient relationship

14. While conducting an assessment of a patient, the nurse recognizes that the initial step is: 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 101 TOP: Assessment

32. When auscultating the thorax, the suggested sequence for a systematic approach is to begin with the: 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 111 TOP: Assessment

21. When performing a nursing physical assessment, the nurse uses a head-to-toe approach. When using this method, the nurse begins with a: a. skin assessment. b. neurological assessment. c. circulatory assessment. d. respiratory assessment.

ANS: B When performing a head-to-toe assessment, the nurse begins with a neurological assessment. REF: Page 107 TOP: Assessment

3. Any disturbance of a structure or function of the body is a pathological condition. This condition is termed a(n): 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 94 TOP: Disease

1. The nurse is collecting data during an initial assessment. The data that can be seen, heard, measured, or felt and is objective is called a(n): a. symptom. b. observation. c. sign. d. assessment.

ANS: C A sign can be seen, heard, measured, or felt. REF: Page 93 TOP: Assessment

48. During a physical assessment, the nurse notes a patient has a lack of appetite resulting in an inability to eat. The nurse should 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 96, Table 5-1 TOP: Assessment

49. During a physical assessment, the nurse notes a patient has a loss of strength and energy. The nurse should document that the patient is experiencing: a. dyspnea. b. cyanosis. c. asthenia. d. ecchymosis.

ANS: C Asthenia is a condition of debility, loss of strength and energy, and depleted vitality. REF: Page 96, Table 5-1 TOP: Assessment

25. The nurse assesses a patient for capillary refill. After the fingernail is compressed for 5 seconds, the refill time should be fewer than: a. 1 second. b. 2 seconds. c. 3 seconds. d. 4 seconds.

ANS: C Capillary refill should take fewer than 3 seconds. REF: Page 115 TOP: Assessment

51. During a physical assessment, the patient complains of difficulty in passing stools. The nurse should 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 96, Table 5-1 TOP: Assessment

52. During a physical assessment, the nurse observes a patient experiencing a sudden audible expulsion of air from the lungs. The nurse should document that the patient is experiencing: a. dyspnea. b. cyanosis. c. coughing. d. ecchymosis.

ANS: 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 96, Table 5-1 TOP: Assessment

23. During a physical assessment, the nurse listens for adventitious lung sounds. Crackles are classified as fine, medium, or coarse and are most often heard: a. during expiration. b. following expiration. c. during inspiration. d. following inspiration.

ANS: C Crackles are usually heard during inspiration. REF: Page 112 TOP: Assessment

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

ANS: C Diabetes mellitus is an example of a chronic disease. REF: Page 95 TOP: Disease

5. The nurse is discussing the origin of diabetes with a diabetic patient. The most appropriate explanation is that this disease is caused by a dysfunction of the: a. pituitary. b. adrenals. c. pancreas. d. thyroid.

ANS: C Diabetes mellitus results from dysfunction of the pancreas. REF: Page 94 TOP: Disease Step: Evaluation

53. During a physical assessment, the nurse notes a patient has profuse secretions of sweat. The nurse should 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 96, Table 5-1 TOP: Assessment

58. When admitting a patient to the hospital, the nurse notes the patient has mild sunburn. The nurse should document this finding as: 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 96, Table 5-1 TOP: Assessment

60. When assessing a patient, the nurse notes a yellow tinge to the patient's skin. The nurse should document that the patient has: 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 96, Table 5-1 TOP: Assessment

42. A physician needs to insert a vaginal speculum into a patient for a vaginal examination. The nurse should place the patient in what position? a. Sims' b. Prone c. Lithotomy d. Dorsal recumbent

ANS: C Lithotomy position provides maximal exposure of genitalia and facilitates insertion of a vaginal speculum. REF: Page 99, Table 5-2 TOP: Assessment

57. A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. The nurse should 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 96, Table 5-1 TOP: Assessment

46. A nurse needs to auscultate a patient's lung sounds. The nurse should place the patient in what position? 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 99, Table 5-2 TOP: Assessment

24. Auscultating the heart sounds should result in a "lubb-dupp" sound when using the bell and the diaphragm of the stethoscope. The "lubb" sound is caused by the: 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 113 TOP: Assessment

15. When collecting data related to the present illness, the nurse must obtain detailed and comprehensive data to assist in establishing: 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 102 TOP: Assessment

11. A nursing assessment is a process of collecting data to establish a database. The information contained in the database is the 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. REF: Page 98 TOP: Assessment

26. Listening for bowel sounds should be done over all four quadrants of the abdomen using the diaphragm of the stethoscope. The normal rate of bowel sounds per minute is: a. 2-10. b. 3-20. c. 4-32. d. 5-40.

ANS: C The normal rate of bowel sounds per minute is 4-32. REF: Page 115 TOP: Assessment

16. During the nursing interview, several histories are taken. The history that involves data concerning habits and lifestyle patterns is called: a. family history. b. environmental history. c. past health history. d. psychosocial history.

ANS: C The nurse identifies habits and lifestyle patterns under past health history. REF: Page 104 TOP: Interview

41. During a neurological 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 brain stem. The function of the oculomotor nerve is essential for eye movements. A traumatic brain injury can result in increased intracranial pressure, edema to the brain stem with pressure on cranial nerve III, causing the ominous sign of a unilateral, dilated, and nonreactive pupil. REF: Page 109 TOP: Assessment

8. The term used to describe a disease where there has been a partial or complete disappearance of clinical and subjective characteristics of the disease is: 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 95 TOP: Disease

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.

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 93 TOP: Assessment

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

ANS: D When performing a head-to-toe assessment, the nurse begins with a neurological 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 116-117 TOP: Assessment

50. During a physical assessment, the nurse notes that a patient's heart rate is 56 beats per minute. The nurse should 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 96, Table 5-1 TOP: Assessment

54. During a physical assessment, the nurse notes a patient passes frequent loose liquid stools. The nurse should 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 96, Table 5-1 TOP: Assessment

45. A physician needs to assess a patient's rectal area. The nurse should place the patient in what position? a. Sims' b. Prone c. Lithotomy d. Knee-chest

ANS: D Knee-chest position provides maximum exposure of the rectal area. REF: Page 99, Table 5-2 TOP: Assessment

44. A physician needs to assess a patient for a heart murmur. The nurse should place the patient in what position? a. Sims' b. Prone c. Lithotomy d. Lateral recumbent

ANS: D Lateral recumbent position aids in detecting heart murmurs. REF: Page 99, Table 5-2 TOP: Assessment

4. The nurse is assessing a patient to collect subjective and objective data. These data will provide the basis for making a: 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 94 TOP: Assessment

33. A nurse is gathering objective data when admitting a patient. Which assessment finding is considered objective? The patient: 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 93 TOP: Assessment

61. When assessing a patient, the nurse notes that the patient is unable to lie flat to breathe. When the nurse assists the patient to a sitting position, the patient is able to breathe more easily. The nurse should 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 96, Table 5-1 TOP: Assessment

63. When assessing a patient, the patient complains of an uncomfortable sensation leading to an urge to scratch. The nurse notes the patient scratching frequently. The nurse should document that the patient is experiencing: 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 96, Table 5-1 TOP: Assessment

64. A physician documents that a patient is having purulent drainage from a wound. The nurse understands that this is most likely caused by: 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 96, Table 5-1 TOP: Assessment

66. A physician documents that a patient has a scleral icterus. The nurse understands this indicates that the color of the patient's sclera is: 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. REF: Page 96, Table 5-1 TOP: Assessment

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. These are identified as: 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 airways. REF: Page 112 TOP: Assessment

19. The patient should be assessed as soon as possible after admission. This initial assessment is done by the: a. physician. b. charge nurse. c. LPN/LVN. d. RN.

ANS: D The initial assessment is done by the registered nurse. REF: Page 106 TOP: Assessment

18. The nurse is developing a nursing care plan for a newly admitted patient. The first step in developing this care plan is a: 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 106 TOP: Assessment

28. Various techniques are used by the nurse when performing a physical assessment. One of these techniques is percussion. Percussion is 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 100, Box 5-4 TOP: Assessment

38. When performing a head-to-toe assessment, the nurse should begin by assessing the patient's: a. support system. b. skin integrity. c. pain level. d. neurological status.

ANS: D When performing a head-to-toe assessment, the nurse begins with a neurological 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 107 TOP: Assessment

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

ANS: D When performing a head-to-toe assessment, the nurse begins with a neurological 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 117 TOP: Assessment