Nokea
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. When did the edema disappear?
- A. 10 to 15 seconds
- B. 20 to 25 seconds
- C. 30 to 35 seconds
- D. 40 to 45 seconds
Correct Answer: A
Rationale: The 2+ pitting edema is identified because the pitting edema disappears in 10 to 15 seconds.
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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.
An unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings is ____.
Correct Answer: pain
Rationale: Pain is an unpleasant sensation caused by noxious (extremely destructive or harmful) stimulation of the sensory nerve endings. It is a cardinal symptom of inflammation and is valuable in the diagnosis of many disorders and conditions. Pain has varied manifestations: mild or severe, chronic, acute, burning, dull or sharp, precisely or poorly localized, or referred.
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. What best identifies these sounds?
- A. Crackles
- B. Plural friction rub
- C. Rhonchi
- D. Sonorous wheezes
Correct Answer: D
Rationale: Sonorous wheezes have a low-pitched, coarse, gurgling, snoring quality and usually indicate the presence of mucus in the trachea and large airways.
When assessing a patient with hepatitis the nurse notes a yellow tinge to the patient's skin. What does the nurse understand as the most likely cause of the jaundice?
- A. Heart
- B. Liver
- C. Brain
- D. Intestines
Correct Answer: B
Rationale: Jaundice is a yellow tinge to the skin; it may indicate obstruction in the flow of bile from the liver.
A nursing assessment is a process of collecting data to establish a database. The information contained in the database is a basis for:
- A. a complete physical examination.
- B. a medical assessment.
- C. an individualized plan of care.
- D. writing nursing orders.
Correct Answer: C
Rationale: The information contained in the database is the basis for an individualized plan of care.