Nokea
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
Correct Answer: D
Rationale: 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.
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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
Correct Answer: C
Rationale: Asthenia is a condition of debility, loss of strength and energy, and depleted vitality.
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
Correct Answer: C
Rationale: Constipation is difficulty in passing stools or an incomplete or infrequent passage of hard stools. There are many causes, both organic and functional.
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
Correct Answer: A
Rationale: Pallor is an unnatural paleness or absence of color in the skin; it may result from a decrease in hemoglobin and erythrocytes.
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
Correct Answer: B
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment.
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
Correct Answer: C
Rationale: Sitting upright provides full expansion of the lungs and provides better visualization of symmetry of upper body parts.