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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.
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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.
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).
The nurse is discussing the origin of diabetes with a diabetic patient. What will the nurse discuss as the most appropriate explanation for the cause of this disease?
- A. Pituitary
- B. Adrenals
- C. Pancreas
- D. Thyroid
Correct Answer: C
Rationale: Diabetes mellitus results from dysfunction of the pancreas.
A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of diplopia
- B. Is experiencing nystagmus
- C. Demonstrates facial grimacing
- D. Has a generalized rash
Correct Answer: A
Rationale: Symptoms are subjective indications of illness that are perceived by the patient. Examples of symptoms are pain, nausea, vertigo, pruritus, diplopia, numbness, and anxiety. The nurse is unaware of symptoms unless the patient describes the sensation. Symptoms are referred to as subjective data. Diplopia is the only subjective assessment finding. All other options are examples of objective data.
When performing a physical examination of a patient the nurse uses a technique that is particularly useful in identifying areas of tenderness or masses of the abdomen. What is this technique?
- A. Auscultation
- B. Deep palpation
- C. Light palpation
- D. Percussion
Correct Answer: B
Rationale: Deep palpation is used to detect tenderness or masses of the abdomen.