Nokea
An older adult patient is being assessed for skin turgor. The nurse identifies decreased skin turgor demonstrated by slow return of the skin to the previous position after being grasped and raised. What can the nurse conclude is responsible for this assessment?
- A. Dehydration
- B. Edema
- C. Skin breakdown
- D. Malnutrition
Correct Answer: A
Rationale: Dehydration results in decreased skin turgor.
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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.
During a physical assessment the nurse notes a patient has a lack of appetite resulting in an inability to eat. What should the nurse document that the patient is experiencing?
- A. Dyspnea
- B. Asthenia
- C. Anorexia
- D. Ecchymosis
Correct Answer: C
Rationale: Anorexia is a lack of appetite resulting in the inability to eat. This symptom can occur in many disease conditions.
A health care provider needs to assess a patient for a heart murmur. In what position should the nurse place the patient?
- A. Sims
- B. Prone
- C. Lithotomy
- D. Lateral recumbent
Correct Answer: D
Rationale: The lateral recumbent position aids in detecting heart murmurs.
The patient should be assessed as soon as possible after admission. Who performs this initial assessment?
- A. Health care provider
- B. Charge nurse
- C. LPN/LVN
- D. RN
Correct Answer: D
Rationale: The initial assessment is done by the registered nurse.
A health care provider documents that a patient is having purulent drainage from a wound. What does the nurse understand is most likely the cause?
- A. Ringworm
- B. Viral infection
- C. Fungal infection
- D. Bacterial infection
Correct Answer: D
Rationale: Purulent drainage is a creamy, viscous, pale yellow or yellow-green fluid exudate that is the result of fluid remains of liquefied necrosis of tissues. Bacterial infection is the most common cause. The character of the pus, including its color, consistency, quantity, or odor, may be of diagnostic significance.