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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
Correct Answer: D
Rationale: 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).
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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
Correct Answer: B
Rationale: The suggested sequence for a systematic auscultation of the thorax is to begin with the apices.
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
Correct Answer: A
Rationale: Risk factors are placed into four categories.
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
Correct Answer: B
Rationale: Symptoms are subjective indications of illness that are perceived by the patient.
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
Correct Answer: C
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
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.