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During a head-to-toe assessment the nurse assesses the patient's abdomen. Which area should the nurse assess next?
- A. Chest
- B. Arms
- C. Legs and feet
- D. Perineal area
Correct Answer: D
Rationale: When performing a head-to-toe assessment, the nurse begins with a neurologic assessment, then assesses the skin, hair, head, and neck, including the eyes, ears, nose, and mouth. The chest, back, arms, abdomen, perineal area, legs, and feet are examined in that order.
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A nurse is gathering subjective data when admitting a patient. Which assessment finding reported by the patient is considered subjective data?
- A. Complains of pruritus.
- B. Is experiencing erythema.
- C. Appears to be experiencing pruritus.
- 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. Pruritus is the only subjective assessment finding. All other options are examples of objective data.
During the nursing interview several histories are taken. What is the history that involves data concerning habits and lifestyle patterns?
- A. Family history
- B. Environmental history
- C. Past health history
- D. Psychosocial history
Correct Answer: C
Rationale: The nurse identifies habits and lifestyle patterns under the past health history.
When discussing diabetes with a patient the nurse describes this disease as falling into which group in terms of duration?
- A. Acute
- B. Organic
- C. Chronic
- D. Functional
Correct Answer: C
Rationale: Diabetes mellitus is an example of a chronic disease.
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.
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.