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A patient was admitted with a complaint of abdominal pain. Later the nurse observed the patient demonstrating dyspnea. What type of assessment does this change in condition require?
- A. Individualized
- B. Focused
- C. Specialized
- D. Systematic
Correct Answer: B
Rationale: When the nurse observes a change in the patient's condition, the assessment is focused.
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Any disturbance of a structure or function of the body is a pathologic condition. What is the term for this condition?
- A. Injury
- B. Condition
- C. Disease
- D. Pathology
Correct Answer: C
Rationale: A disease is any disturbance of a structure or function of the body.
A health care provider needs to assess a patient's rectal area. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Knee-chest
Correct Answer: D
Rationale: Knee-chest position provides maximum exposure of the rectal area.
What does the nurse recognize as the initial step in conducting an assessment of a patient?
- A. A body systems review
- B. The nursing health history
- C. Biographic data
- D. The present illness
Correct Answer: B
Rationale: The nursing health history is the initial step in the assessment process.
Signs that are perceived by an examiner and can be seen ____ measured or felt are known as objective data.
Correct Answer: heard
Rationale: Objective data is a sign that can be seen, heard, measured, or felt by the examiner.
During a physical assessment the nurse notes a patient passes frequent loose liquid stools. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Cyanosis
- C. Diaphoresis
- D. Diarrhea
Correct Answer: D
Rationale: Diarrhea is the frequent passage of loose liquid stools. It generally results from increased motility in the colon. This is usually a sign of an underlying disorder. The characteristics of the diarrhea give evidence as to the source. Dark black, tarry stools can mean there is bleeding in the intestines. Bright red blood in the feces indicates active bleeding from the lower portion of the intestinal tract.