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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
Correct Answer: A
Rationale: Sallow is an unhealthy, yellow color; usually said of a complexion or skin.
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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
Correct Answer: D
Rationale: 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.
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
Correct Answer: D
Rationale: 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.
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
Correct Answer: D
Rationale: 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.
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
Correct Answer: A
Rationale: 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.
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.
Correct Answer: health
Rationale: 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.