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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
Correct Answer: A
Rationale: Dyspnea is shortness of breath or difficulty in breathing that may be caused by certain heart and lung conditions, strenuous exercise, or anxiety.
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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
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 pruritus.
- B. Is experiencing erythema.
- C. Appears to be experiencing pruritus.
- 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. Pruritus is the only subjective assessment finding. All other options are examples of objective data.
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.
Correct Answer: B
Rationale: The first step in a nurse-patient relationship is for the nurse to introduce herself/himself.
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
Correct Answer: D
Rationale: Nurses rely on assessment of signs and symptoms to formulate a patient problem.
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.